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.
|Acute Inpatient Rehabilitation Services||C.3.06|
|Airway Clearance Devices in the Ambulatory Setting*||C.11.01|
|Ambulatory ECG Monitoring||C.6.20|
|Bioengineered Skin Substitutes*|
|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 Therapy||C.6.30|
|Cell-free DNA Testing for Fetal Aneuploidy||C.6.17|
|Continuous Glucose Monitoring Devices||C.11.09|
|Continuous Passive Motion (CPM) Devices*||C.11.15|
|Cosmetic and Reconstructive Surgery||C.5.14|
|Cranial Orthosis for Treatment of Craniosynostosis||C.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 Stiffness*|
|Electric Tumor Treatment Fields (TTF) Device||C.11.23|
|Endoscopic Myotomy Procedures for Treatment of Esophageal Achalasia and Gastroparesis||C.5.32|
|Endoscopic Procedures & Non-Endoscopic Devices for Gastroesophageal Reflux Disease||C.5.27|
|External Electrical Stimulators: Neuromuscular Electrical Stimulation (NMES), and Transcutaneous Electrical Nerve Stimulator (TENS)*|
|Excimer Laser for Treatment of Psoriasis||C.6.28|
|Endoscopic Procedures and Non-endoscopic Devices for Gastroesophageal Reflux Disease*|
|Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions||C.5.11|
|Gender Reassignment Surgery||C.5.29|
|Gender Reassignment Surgery – ETF||C.5.36|
|Genetic Testing for Breast, Ovarian, Pancreatic or Prostate Cancer Syndromes including BRCA||C.6.21|
|Heart Failure-Remote Monitoring (CardioMEMS™)||C.6.23|
|Home Health Care||C.9.01|
|Home Phototherapy Devices (Narrowband UVB)||C.11.25|
|Hospital Bed Rental/Purchase and Accessories*|
|Hyperbaric Oxygen Therapy (HBOT)*|
|Insulin Pump and Continuous Glucose Monitoring Systems*|