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Medical Policies

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. 


SUMMARY OF BENEFITS & COVERAGE LOOKUP

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.

Medical PolicyPolicy Number
Acute Inpatient Rehabilitation ServicesC.3.06
Airway Clearance Devices in the Ambulatory Setting*C.11.01
Ambulatory ECG MonitoringC.6.20
Artificial Disc* 
Bariatric SurgeryC.5.23 
Bioengineered Skin Substitutes* 
BiofeedbackC.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* 
CAR T Cell TherapyC.6.30
Cell-free DNA Testing for Fetal AneuploidyC.6.17
Cochlear Implants* 
Continuous Glucose Monitoring DevicesC.11.09
Continuous Passive Motion (CPM) Devices*C.11.15
Cosmetic and Reconstructive SurgeryC.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 Stimulation* 
Dynamic Low-Load Prolonged-Duration Stretch (LLPS) Devices for Treatment of Contracture and Joint StiffnessC.11.12 
Electric Tumor Treatment Fields (TTF) DeviceC.11.23
Endoscopic Myotomy Procedures for Treatment of Esophageal Achalasia and GastroparesisC.5.32
Endoscopic Procedures & Non-Endoscopic Devices for Gastroesophageal Reflux DiseaseC.5.27
External Electrical Stimulators: Neuromuscular Electrical Stimulation (NMES), and Transcutaneous Electrical Nerve Stimulator (TENS)* 
Excimer Laser for Treatment of PsoriasisC.6.28
Endoscopic Procedures and Non-endoscopic Devices for Gastroesophageal Reflux Disease* 
Extracorporeal Shock Wave Therapy for Musculoskeletal ConditionsC.5.11
Gender Affirming SurgeryC.5.29
Gender Affirming Surgery – ETFC.5.36
Genetic TestingC.6.07
Genetic Testing for Breast, Ovarian, Pancreatic or Prostate Cancer Syndromes including BRCAC.6.21
Heart Failure-Remote Monitoring (CardioMEMS™)C.6.23
Home Health CareC.9.01
Home Phototherapy Devices (Narrowband UVB)C.11.25
Hospice ServicesC.12.01
Hospital Bed Rental/Purchase and Accessories* 
Hyperbaric Oxygen Therapy (HBOT)* 
Infertility ServicesC.6.12
Insulin Pump and Continuous Glucose Monitoring Systems* 
ProcedureBilling Code
Left Atrial Appendage Closure 
Life-Sustaining Enteral NutritionC.6.05
Long Term Acute Care (LTAC) 
Lymphedema* 
Manual WheelchairsC.11.02
Negative Pressure Wound Therapy for Adults* 
Non-Invasive Fractional Flow Reserve Calculation after Coronary CT Angiography (FFR-CT)C.6.36
Obstructive Sleep Apnea – Non-Surgical Treatment with Oral ApplianceC.11.06
Obstructive Sleep Apnea – Surgical TreatmentC.5.04
Patient Lift Equipment* 
Pectus Carinatum Orthotic Devices and Surgical CorrectionC.11.27
Pediatric Standing Frames or Stander* 
Penile Implants 
Peripheral Nerve Stimulation* 
Pharmacogenetic TestingC.6.16
Photodynamic TherapyC.6.15
Platelet-Rich Plasma (PRP) InjectionsC.13.01
Pneumatic Cervical Traction DevicesC.11.17
Prenatal/Preconception Genetic Testing to Determine Carrier State of a Parent or Prospective ParentC.6.18
ProlotherapyC.16.13
Prostate Artery EmbolizationC.6.33
Proton Beam Therapy* 
Ptosis – Surgical Procedures* 
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 LossC.6.29
Rhinoplasty / Septorhinoplasty* 
Robotic ProceduresC.5.19
Skilled Nursing Facility (SNF) ServicesC.3.04
Solid Organ and Hematopoietic Stem Cell TransplantationC.5.17
Sphenopalatine Ganglion BlockC.6.22
Spinal Cord Stimulation* 
Surgical Repair of Cartilage, Ligament, and Meniscal Defects of the KneeC.5.33 
Surgical Treatment for Varicose Veins and Venous Insufficiency* 
Surgical Treatment of Temporomandibular Joint (TMJ) DisordersC.8.01
Therapeutic Shoes and Custom-Molded InsertsC.11.19
Thermal Intradiscal ProceduresC.5.22
Transcatheter Closure of Septal DefectC.11.22
Treatment of Obstructive Sleep Apnea Non-surgical* 
Treatment of Urinary and Fecal IncontinenceC.5.13
Tumor Marker GeneticsC.6.34
Vagus Nerve Stimulation for Seizure Disorders* 
Wearable Cardioverter Defibrillator* 
Whole Exome and Whole Genome SequencingC.6.35
* contact Quartz Medical Management for details at 888-829-5687. 

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