Medical policies for providers
See the latest updates to our medical policies.
MP091-Sacral Nerve Stimulation (Interstim)
A sacral nerve stimulator is composed of a pulse generator that transmits electrical impulses to the sacral nerves through an implanted wire electrode. These electrical impulses cause a contraction of the bladder muscles, giving the patient improved bl...
MP301-Sacroiliac Joint Fusion
Sacroiliac joint fusion is a surgical procedure which fuses the pelvis to the sacrum to provide stabilization
MP295-Sacroiliac Joint Injection
MP162-Salivary Hormone Testing for Menopause and Aging
Saliva can be analyzed for lipid-soluble hormones such as estrogen, testosterone, progesterone, melatonin, cortisol and DHEA (Dehydroepiandrosterone). Salivary hormone levels reflect the free, unbound and active, hormone concentration. Measurements of ...
MP208-Selective Internal Radiation Therapy (aka, Intrahepatic Radioembolization)
Selective Internal Radiation Therapy (aka, Intrahepatic Radioembolization) involves the use of Intra-hepatic microspheres which are radio-labeled particles composed of glass or resin polymers. The spheres are tagged with Y-90 and injected via the hepat...
MP177-Sensory Integration Therapy
Sensory integration therapy (SIT) is intended to improve one’s ability to process and integrate sensory information and provide a basis for improved independence and participation in daily life activities. Performed by an occupational/ physical therapi...
MP218-Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease
The Prometheus system is a commercially available diagnostic system that uses combinations of tests for ANCA and/or ASCA to aid in the diagnosis of Inflammatory Bowel Disease(IBD). Tests/test panels include, but are not limited to the following:Promen...
MP078-Sexual Dysfunction Therapies
Sexual dysfunction describes any of a group of sexual disorders characterized by the inhibition of sexual desire or the physiological changes that characterize inhibition of sexual response. Male impotency is a form of sexual dysfunction characterized ...
MP248-Single Nucleotide Polymorphisms (SNPs) to Predict Risk of Non-Familial Breast Cancer
Single nucleotide polymorphisms, usually referred to as SNPs, are small genetic changes among single base nucleotides. Researchers suggest that SNPs in functional regions of genes involved in sex hormone synthesis, signaling and metabolism may differen...
MP020-Solid Organ Transplant Services
Approved solid organ transplantation is covered when medically indicated. Transplant evaluation, transplant services and post-transplant care are coordinated through the current contracted transplant management vendor.
MP040-Somnoplasty, Coblation (Radiofrequency Ablation)
Somnoplasty utilizes low-power, low-temperature radiofrequency energy as a treatment for nasal airway obstruction, obstructive sleep apnea and/or snoring. By means of a partially insulated electrode, radiofrequency energy is delivered into the soft pal...
MP227-Spaced Retrieval Training
Spaced-Retrieval (SR) is a memory intervention that gives individuals practice at successfully recalling information over progressively longer intervals of time. The goal of SR is to enable individuals to remember important information for clinically m...
MP275-Speech Generating Devices
Speech-generating devices are electronic augmentative and alternative communication systems used to supplement or replace speech or writing for individuals with severe speech impairments, enabling them to verbally communicate their needs.
MP318-Sphenopalatine Gangloin Block for Headache
Sphenopalatine ganglion (SPG) nerve block via an intranasal topical anesthetic has been proposed as a treatment for chronic migraine and severe non-migraine headache. The SPG is located behind the bony structures of the nose and is linked to the trigeminal nerve, the primary nerve involved in headache disorders.
MP084-Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
Stereotactic radiosurgery and Stereotactic Body Radiation Therapy are is a non-invasive method of delivering high doses of ionizing radiation utilizing three-dimensional planning of stereotactic and convergent beam technologies to small intracranial, s...
Suit therapy has been proposed as an alternative treatment for impairments associated with sensory integration disorders, cerebral palsy and other neuromuscular conditions. The Adeli suit (Also known as Therasuit, Penguin suit, and Polish suit) works a...
MP221-Suprachoroidal Delivery of Pharmacologic Agents
Suprachoroidal delivery of pharmacologic agents is currently being investigated as a means to deliver higher levels of drug to the targeted tissue. The technique involves the use of a microcannula system that serves as a drug delivery channel...
MP048-Surgical and Minimally Invasive Therapies for the Treatment of Benign Prostatic Hypertrophy
Transurethral Microwave Thermotherapy (TUMT), Transurethral Radiofrequency Thermotherapy (TUNA), Laser Prostatectomy, and Water Induced Thermotherapy (WIT) are outpatient ablation treatments for symptomatic benign prostatic hypertrophy (BPH). These pro...
MP050-Surgical Correction of Chest Wall Deformities
Pectus Excavatum is characterized by a concave, posteriorly displaced sternum due to overgrowth of the costal cartilages. The defect is a progressive deformity that usually presents at birth or early in life, but can become exaggerated during growth pe...
MP292-Sympathetic Nerve Block
Sympathetic therapy is a non-invasive type of bilateral electrical stimulation of the peripheral nerves that is theorized to stimulate the sympathetic nervous system in an effort to “normalize” the autonomic nervous system and alleviate chronic pain. U...
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