The Medical Policies listed below are examples provided for informational purposes only.

These Medical Policies do not constitute medical advice. When deciding coverage, the terms of the enrollee’s plan and any applicable laws are referenced.

Plan terms are found in plan documents including but not limited to Certificates of Coverage, Benefit Riders and Summary Plan Descriptions. 

The terms of an enrollee’s plan may differ from these Medical Policies. In the event of a conflict, the terms of the enrollee’s plan supersede the Medical Policy.

The list below is not a comprehensive list of Medical Policies. More recent versions of the Medical Policies, additional Medical Policies, InterQual® criteria, and Coverage Determination Guidelines may also apply.

Acupuncture

C.6.31

Acute Inpatient Rehabilitation Services

C.3.06

Airway Clearance Devices in the Ambulatory Setting

C.11.01

Ambulatory EGC Monitoring

C.6.20

Artificial Disc

C.5.21

Autism Spectrum Disorder

C.2.07

Bariatric Surgery

C.5.23

Bioengineered Skin Substitutes

C.5.25

Biofeedback

C.6.25

Bone Anchored Hearing Aid (BAHA)

C.5.20

Bone Growth Stimulation

C.11.05

Breast Reconstruction Post Mastectomy or Partial Mastectomy

C.5.03

Breast Reduction Surgery

C.5.02

CAR T Cell Therapy

C.6.30

Cochlear Implants

C.5.10

Continuous Passive Motion (CPM) Devices

C.11.15

Corneal Cross-linking for Treatment of Keratoconus (aka Corneal Ectasia)

C.5.28

Cosmetic and Reconstructive Surgery

C.5.14

Cranial Orthosis for Treatment of CraniosynostosisC.11.26

Criteria for Rental, Replacement, Repair, Upgrade or Purchase of Durable Medical Equipment (DME)

C.11.18

Deep Brain StimulationC.5.34

Dynamic Low-load Prolonged-Duration Stretch (LLPS) Devices for Treatment of Contracture and Joint Stiffness

C.11.12

Electric Tumor Treatment Fields (TTF) Device

C.11.23

External Electrical Stimulators: Neuromuscular Electrical Stimulation (NMES), and Transcutaneous Electrical Nerve Stimulator (TENS)

C.11.13

Excimer Laser for Treatment of Psoriasis

C.6.28

Endoscopic Procedures and Non-Endoscopic Devices for Gastroesophageal Reflux Disease

C.5.27

Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions

C.5.11

Fecal Bacteriotherapy for the Treatment of Recurrent Clostridium Difficile Infection

C.6.19

Gender Reassignment Surgery for ETF ParticipantsC.5.36

Genetic Testing

C.6.07

Genetic Testing for BRCA-Related Breast and/or Ovarian Cancer Syndrome

C.6.21

Heart Failure-Remote Monitoring (CardioMEMS™)

C.6.23

Hip Resurfacing Arthroplasty

C.5.15

Home Health Care

C.9.01

Home Phototherapy Devices (Narrowband UVB)

C.11.25

Hospice Services

C.12.01

Hospital Bed Rental/Purchase and Accessories

C.11.16

Hyperbaric Oxygen Therapy (HBOT)

C.6.11

Infertility Services

C.6.12

Insulin Pump and Continuous Glucose Monitoring Systems

C.11.09

Life-Sustaining Nutrition

C.6.05

LymphedemaC.11.28

Manual Wheelchairs

C.11.02

Negative Pressure Wound Therapy for Adults

C.6.14

Non-Invasive Fetal Aneuploidy Testing

C.6.17

Obstructive Sleep Apnea - Surgical Treatment

C.5.04

Patient Lift Equipment

C.11.04

Pectus Carinatum Orthotic Devices and Surgical CorrectionC.11.27

Pediatric Standing Frames or Stander

C.11.24

Peripheral Nerve Stimulation

C.5.31

Peroral Endoscopic Myotomy (POEM) for Treatment of Achalasia

C.5.32

Pharmacogenetic Testing

C.6.16

Photodynamic Therapy (PDT) for Skin Lesions

C.6.15

Platelet-Rich Plasma (PRP) Injections

C.13.01

Pneumatic Cervical Traction Devices

 C.11.17

Prenatal /Preconception Genetic Testing to Determine Carrier State of a Parent or Prospective Parent

C.6.18

Prolotherapy

C.16.13

Prostate Artery EmbolizationC.6.33

Prostatic Urethral Lift - Urolift

C.5.24
Proton Beam TherapyC.6.32

Ptosis – Surgical Procedures

C.5.07

Purchase of Motorized Wheelchairs/Power Operated Vehicles (Scooters)

C.11.03

Radioembolization with Yttrium-90 Microspheres (TheraSphere and SIR-Spheres)

C.6.24

Recurrent Pregnancy Loss

C.6.29

Rental of Hospital Grade Electric Breast Pumps

C.11.11

Rhinoplasty/Septorhinoplasty

C.5.09

Robotic Procedures

C.5.19

Sacral Nerve Stimulation for Urinary and Fecal Incontinence

C.5.13

Skilled Nursing Facility (SNF) Services

C.3.04

Sphenopalatine Ganglion Block

C.6.22

Spinal Cord Stimulation

C.11.20

Steroid Releasing Implant following Endoscopic Sinus Surgery

C.5.30

Surgical Repair of Cartilage, Ligament and Meniscal Defects of the KneeC.5.33 

Surgical Treatment for Gender Dysphoria

C.5.29

Surgical Treatment for Varicose Veins and Venous Insufficiency

C.5.06

Surgical Treatment of Temporomandibular Joint (TMJ) Disorders

C.8.01

Therapeutic Shoes and Custom-Molded Inserts

C.11.19

Thermal Intradiscal Procedures

C.5.22

Transcatheter Closure of Septal Defect

C.11.22

Transperineal Placement of Biodegradeable Material (SpaceOAR) for Prostate CancerC.5.35

Transplants

C.5.17

Treatment of Obstructive Sleep Apnea Non-Surgical

C.11.06

Tumor Marker Genetics

C.6.34

Vagus Nerve Stimulation for Seizure Disorders

C.5.16

Wearable Cardioverter Defibrillator

C.11.21

Whole Exome and Whole Genome SequencingC.6.35

For copies of Medical Policies specific to your plan, please contact Medical Management at (888) 829-5687. Medical Policies are the property of Quartz Health Solutions, Inc. Unauthorized use and distribution of these Medical Policies is strictly prohibited.