Medical policies for providers
See the latest updates to our medical policies.
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.
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 involves placement of a probe within the intervertebral disc under image guidance with mechanical aspiration of disc material using a suction cutting device.
MP343-Percutaneous Electrical Nerve Field Stimulation (PENFS) for Treatment of Functional Abdominal Pain
Percutaneous Electrical Nerve Field Stimulation (PENFS) has been proposed as a treatment of functional abdominal pain secondary to inflammatory bowel disease in children and adolescents.
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.
MP319-Percutaneous Left Atrial Appendage Occlusion
Percutaneous occlusion of a left atrial appendage (LAA) is a treatment strategy designed to prevent clots from originating in and traveling out of the LAA and potentially causing a stroke in adults with non-valvular atrial fibrillation.
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.
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.
MP345-Peroral Endoscopic Myotomy (POEM)
Peroral endoscopic myotomy (POEM) is a hybrid technique derived from natural orifice transluminal endoscopic surgery and advances in endoscopic submucosal dissection to perform a myotomy.
MP179-Photodynamic Therapy for Oncology Applications
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.
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).
MP355-Plasma-based Proteomic Testing in the Management of Pulmonary Nodules
Plasma-based proteomic screening has been investigated as a tool to risk-stratify pulmonary nodules. Nodules identified as likely benign would allow members to undergo serial CT scans of their nodules (active surveillance), instead of undergoing invasive procedures such as CT-guided biopsy or surgery. Additionally, proteomic testing may also determine a likely malignancy in clinically low-risk or intermediate-risk pulmonary nodules, thereby permitting earlier detection.
MP217-Polysomnography and Sleep Studies
Polysomnography testing is used to diagnose sleep disorders.
MP357-Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer
The DetermaRx 14-Gene Lung Cancer Assay is quantitative PCR analysis designed to be used on formalin-fixed, paraffin embedded lung cancer tissue.
MP367-Prescription Digital Therapeutics
Prescription digital therapeutics (PDTs) are software applications that are prescribed by a licensed healthcare practitioner legally authorized to prescribe medications and devices.
MP046 -Progressive Stretch Devices
A dynamic splint has moving parts to allow mobility by providing forces that substitute for weak or absent muscle strength.
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.
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 and degenerated discs.
Prophylactic mastectomy is the removal of the breast in the absence of malignant disease in insured individuals with significant risk factors for breast carcinoma.
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.
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.
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.
MP226-Proton Beam Radiation
Proton beams are one of several types of subatomic particles that have been used the treatment of malignancies.
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.
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