Medical policies for providers

See the latest updates to our medical policies. 

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P

MP272-PCA3 and Gene Expression Assays for Prostate Cancer
Prostate cancer antigen 3 (PCA3, also referred to as DD3) is a gene that expresses a non-coding RNA. PCA3 is only expressed in human prostate tissue, and the gene is highly overexpressed in prostate cancer. Because of its restricted expression profile,... 

MP244-Pelvic Floor Stimulation
Pelvic Floor Stimulation (PFS) involves the electrical stimulation of the pelvic floor muscles using either a probe wired to a device for controlling the electrical stimulation or, more recently, extracorporeal pulsed magnetic innervation. It is believ... 

MP072-Percutaneous Disc Decompression (Nucleoplasty)
Percutaneous manual disc decompression utilizing a cutting forceps or automated mechanical intervertebral disc decompression utilizing a StrykerDekompressor® (a.k.a. Automated Percutaneous Nucleotomy) or SpineJet hydrodiskectomy is considered medically...

MP251-Percutaneous Heart Valve Replacement
Percutaneous (transcatheter) heart valve replacement (PHV) is catheter-based technology that allows for implantation of a prosthetic valve without open-heart surgery.  The prosthetic heart valve is delivered via a catheter inserted either through a vei...

MP088-Percutaneous Laser Lumbar Diskectomy
Laser diskectomy is a minimally invasive alternative to open surgical or mechanical methods of disc decompression for the treatment of symptomatic intervertebral disc herniation that has not responded to conservative therapy.  The primary goals of lase...

MP219-Percutaneous Neuromodulation Therapy
Percutaneous neuromodulation therapy (PNT) is a variant form of Percutaneous Electrical Nerve Stimulation (PENS) in which up to 10 fine filament electrodes are temporarily placed at specific anatomical landmarks in the back. Treatment regimens...
 

MP302-Percutaneous Tibial Nerve Stimulation (PTNS)
Percutaneous Tibial Nerve Stimulation (PTNS) is a procedure that delivers retrograde access to the sacral nerve plexus via electrical stimulation of the posterior tibial nerve. Also referred to as posterior tibial nerve stimulation, this treatment i...

MP239-Pharmacogenetic Testing

MP179-Photodynamic Therapy for Esophageal and Lung Cancer
Photodynamic therapy (also known as phototherapy, photoradiation therapy, photosensitizing therapy, and/or photochemotherapy) consists of the use of a photosensitizing agent and the subsequent exposure of tumor cells to a laser light source in order to...

MP105-Phototherapy for Seasonal Affective Disorder
Seasonal affective disorder (SAD) is defined as a history of major depressive episodes that recur regularly at a particular time of year, typically winter. SAD is associated with decrease in ambient light exposure during the winter season. Based on thi...

MP259-Phototherapy for the Treatment of Dermatological Conditions
Phototherapy is defined as the exposure to Ultraviolet radiation for the therapeutic use of skin conditions.  The various therapies include Psoralen with Ultraviolet A (PUVA), Ultraviolet A or B, laser UVB, an UVB plus coal tar (Goeckerman regimen). UV...

MP217-Polysomnography and Sleep Studies
Polysomnography testing is used to diagnose sleep disorders. It includes the following measurements: the electrophysiologic indices of sleep staging (EEG, EOG, EMG); electromechanical indices contrasting respiratory effort with actual ventilation (c...

MP046 -Progressive Stretch Devices
A dynamic splint has moving parts to allow mobility by providing forces that substitute for weak or absent muscle strength. Dynamic splinting can be used in conjunction with a medically supervised treatment program to restore range of motion to patient...

MP273-Prolaris® Post-Prostatectomy Test
Prolaris® is a genomic test developed to aid physicians in predicting prostate cancer aggressiveness in conjunction with clinical parameters such as Gleason score and PSA. Prolaris® is a direct molecular measure of prostate cancer tumor biology. By mea...

MP127-Prolotherapy
Prolotherapy is a method of treating musculoskeletal pain.  Prolotherapy promotes a localized inflammatory reaction by injecting proliferants into the damaged tendon or ligament to help stimulate the healing process. Prolotherapy is intended to increas...

MP229-Prolozone® Therapy
Prolozone® Therapy is a homeopathic injection technique proposed to treat all forms of musculoskeletal and joint pain including chronic neck and back pain, rotator cuff injuries, degenerative and arthritic hips and knees, degenerated discs, and shoulde...

MP054-Prophylactic Mastectomy
Prophylactic mastectomy is the removal of the breast in the absence of malignant disease in insured individuals with significant risk factors for breast carcinoma.

MP057-Prophylactic Oophorectomy
Prophylactic oophorectomy is the removal of both ovaries for the potential benefit of preventing the development of ovarian cancer in women who are at high risk for the disease. Current screening methods for ovarian cancer are not sensitive enough to d...

MP265-Proteomic Serum Analysis
OvaCheck®, developed by Correlogic Systems Inc, is a serum-based test that uses proteomics for the early detection of ovarian cancer. The test is based on proteomic patterns detected in the serum, which are then further analyzed with the use of a mass ...

MP157 -Prothrombin Time Home Testing
Home prothrombin time testing systems are portable, hand-held, battery operated devices designed to analyze fresh capillary blood samples obtained by finger-stick using a lancet device. Both prothrombin time (PT) and international normalized ratio (INR...

MP226-Proton Beam Radiation
Proton beams are one of several types of subatomic particles that have been used the treatment of malignancies. Proton beams are particulate radiation therapy, which differs from photon and/or conventional electromagnetic radiation therapy because of i...

MP149-Pulsed Electrical Stimulation for the Treatment of Osteoarthritis
Pulsed electrical stimulation has been proposed as a treatment for symptomatic relief in osteoarthritis. One such device is marketed as the BioniCare® BIO-1000™ system.

MP198-Pulse Oximetry for Pediatric Home Use
Pediatric – For the purposes of this policy, the term pediatric will refer to Insured individuals under 21 years of age.Pulse Oximetry is a non-invasive method of monitoring arterial blood oxygenation. Changing absorbance of each of the two wave... 

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