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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 


MP282-Termination of Pregnancy

MP119-Therapeutic Listening
Therapeutic listening, also known as sound training, is a technique, which uses modified music in an effort to stimulate interconnections between the ear and the nervous system to integrate aspects of human development and behavior. This alternative th...

MP161-Thermal Capsulorrhaphy
Thermal Capsulorrhaphy, also known as electrothermal therapy or capsular shrinkage, is proposed as a treatment for shoulder instability and cruciate ligament laxity. Radiofrequency or electrothermal energy is applied to the ligament theoretic...

Thermography, also known as temperature-gradient studies, is a non-invasive imaging technique intended to measure temperature distributions of various organs and tissues. The infrared radiation from the tissue reveals temperature variations by pr...

MP254-Tinnitus Treatment
Tinnitus is the perception of sound in the ear, commonly described as “head noise”, in the absence of external stimulus.  Tinnitus is a malfunction of auditory signal processing, and often results from a hearing impairment (either noise-induced or age ...

MP75-Tissue Engineered Skin Substitutes
Tissue engineered skin substitutes have been developed to replace autografts, allografts and xenograft in the treatment of extensive burn injuries and hard-to-heal, chronic wounds associated with non-burn etiologies such as venous ulcers and diabetic f...


MP224-Topical Oxygenation
Topical oxygenation, also referred to as topical hyperbaric oxygenation, is the use of 100% oxygen applied at just above atmospheric pressure to moist open wounds. The theory behind this therapy is that the increase in oxygen at the surface o...

MP235-Total Facet Arthroplasty
Total Facet Arthroplasty refers to the implantation of a spinal prosthesis to restore posterior element structure and function as an adjunct to neural decompression. The procedure is proposed for use as an alternative to posterior spinal fusi... 

MP129-Total Parenteral Nutrition
Total parenteral nutrition (TPN) is a type of nutritional care involving the use of intravenous fluids containing fats, carbohydrates, proteins, vitamins and other substances administered through a centrally placed catheter.

MP154-Transanal Radiofrequency Therapy for Fecal Incontinence (Secca®)
Radiofrequency energy delivered to the sphincteric complex via an anoscopic device is being purported as a treatment for fecal incontinence. The device (Secca® system) creates thermal lesions in the mucosa of the anal canal. It is theorized that as the...

MP25-Transcatheter Closure Devices for Cardiac Defects
Transcatheter closure devices for treatment of cardiac defects are permanent cardiac implants designed to close defects between chambers of the heart. The device is implanted during a transcatheter hole closure procedure performed in the cardiac cathet...

MP62-Transmyocardial Laser Revascularization
Transmyocardial laser revascularization (TMLR) is a procedure that attempts to improve blood flow to ischemic heart muscle through the creation of channels from the left ventricle to the myocardium. This procedure is used as a late or last resort for r...

MP256-Transoral Incisionless Fundoplication
Transoral Incisionless Fundoplication, including but not limited to the EndoGastric Solutions SerosaFuse™ implantable fasteners, and associated EsophyX delivery device and accessories consist of sterile polypropylene fastener implants and an ergonomic,...

MP124-Transpupillary Thermotherapy
Transpupillary thermotherapy (TTT) involves the use of an infrared laser as a treatment to destroy intraocular tumors or to treat and prevent inappropriate new blood vessel growth in the eye due to age-related macular degeneration. 

MP237-Transurethral radiofrequency tissue remodeling
Transurethral radiofrequency tissue remodeling has been proposed as a treatment of urinary stress incontinence. Unlike traditional radiofrequency which causes tissue necrosis, this procedure utilizes lower temperatures and has been proposed to shrink a...

MP289-Treatment of Dry Eye Syndrome
Dry eye disease is a multifactorial disease of the tears and ocular surface that can result in ocular discomfort and visual impairment. Dry eye is also known as keratoconjunctivitis sicca, dry eye syndrome, and dysfunctional tear syndrome.

MP165-Treatment of Vestibular Disorders
Particle repositioning maneuvers (i.e. Epley Canalith maneuver and/or Semont Maneuver) is a series of rotational maneuvers of the head and body designed to relocate displaced otoconia and other material from a foreign location in one of the semicircula...

MP175-Trigger Point Injections
Trigger points are focal, discrete areas of inflammation occurring in skeletal muscle as a response to either acute or chronic muscle strain. The pain produced presents in a pattern characteristic for the specific muscle involved. Trigger point inj...

MP306-Tumor Treatment Fields
Tumor Treating Fields, or TTF are low intensity, alternating electric fields within the intermediate frequency range. TTF disrupts cell division through physical interactions with key molecules during mitosis. TTF are generated via pairs of transducer ...

MP291-TX1 Tissue Removal System for Ablating and Removing Tissue (aka percutaneous tenotomy)
The TX1™ Tissue Removal System is a minimally invasive ultrasonic surgical aspirator intended for ablating and removing diseased or pathologic musculoskeletal tissue.

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