Medical Policies

Most of the links below will open as PDFs.

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

Preventative Guidelines | Clinical Guidelines

A Policies

• Accommodating Intraocular Lens (Crystalens, ReStore, Synchrony) (PDF)
• Acupuncture (PDF)
• ADHD Assessment and Testing (PDF)
• Allergy Testing and Therapy (PDF)
• Allogeneic Hematopoietic Cell Transplant for Sickle Cell Disease (PDF)
• Ambulance Transportation, Non-Emergent (PDF)
• Ambulatory EEG (PDF)
• Ambulatory Surgery Center Optimization (PDF)
• Antithrombin III (PDF)
• Applied Behavioral Analysis (ABA) (PDF)
• Assisted Reproductive Technologies and Infertility (PDF)
• Articular Cartilage Defect Repairs (PDF)
• Artificial Retina (PDF)
• Autism Diagnosis and Treatment (PDF)
• Automated Ambulatory Blood Pressure Monitoring (PDF)

B Policies

• Balloon Sinuplasty for Treatment of Chronic Sinusitis (PDF)
• Bariatric Surgery (PDF)
• Benign Skin Lesion Removal (PDF)
• Biofeedback (PDF)
• Bone Anchored Hearing Aids (BAHA) (PDF)
• Bronchial Thermoplasty (PDF)

C Policies

• Cardiac Biomarker Testing in Acute MI (PDF)
• Cardiac Rehabilitation, Outpatient (PDF)
• Cardiac Risk Assessment-Laboratory Tests (PDF)
• Carrier Screening in Pregnancy (PDF)
• Caudal or Interlaminar Epidural Steroid Injections (PDF)
• Celiac Disease Testing (PDF)
• Cell-free Fetal DNA Testing (PDF)
• Central Auditory Processing Disorder (PDF)
• Chelation Therapy (PDF)
• Clinical Trials (PDF)
• Cochlear Implant Replacements (PDF)
• Corneal Collagen Cross-linking (PDF)
• Cosmetic and Reconstructive Surgery (PDF)

D Policies

• Dental Anesthesia (PDF)
• Digital EEG Analysis (PDF)
• Disc Decompression Procedures - Percutaneous and Laser (PDF)
• Discography (PDF)
• DME (PDF)
• DNA Analysis of Stool to Screen for Colorectal Cancer (PDF)
• Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Stem Cell Transplantation (PDF)
• Double Balloon Enteroscopy (PDF)

E Policies

• Early Elective Deliveries Before 39 Weeks Gestation (PDF)
• EEG for Headache (PDF)
• Electric Tumor Treatment Fields (PDF)
• Endometrial Ablation (PDF)
• Enhanced External Counterpulsation (EECP) (PDF)
• EpiFix Wound Treatment (PDF)
• Essure Removal (PDF)
• Evoked Potentials (PDF)

F Policies

• Facial Lipodystrophy Treatments (i.e. Sculptra and Radiesse) (PDF)
• Facet Join Intervention (PDF)
• Fecal Bacteriotherapy (PDF)
• Fecal Incontinence Treatments (PDF)
• Ferriscan (PDF)
• Fertility Preservation (PDF)
• Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)
• Fixed Wing Air Transportation (PDF)
• Fractional Exhaled Nitric Oxide (PDF)
• Functional MRI (PDF)

G Policies

• Gastric Electrical Stimulation (PDF)
• Gender Affirming Procedures (PDF)
• Genetic Testing (PDF)
• Genetic Testing for Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) (PDF)
• Growing Rods Spinal Surgery (PDF)

H Policies

• H. Pylori Serology Testing (PDF)
• Heart-Lung Transplant (PDF)
• Holter Monitor (PDF)
• Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)
• Homocysteine Testing (PDF)
• Hospice Care (PDF)
• Hyperbaric Oxygen Therapy (PDF)
• Hyperhidrosis Treatments (PDF)
• Hyperemesis Gravidarum Treatment (PDF)

I Policies

• Implantable Hypoglossasl Nerve Stimulation (PDF)
• Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
• Implantable Intrathecal Pain Pump (PDF)
• Implantable Miniature Telescope Screening for Age Related Macular Degeneration (PDF)
• Infusion Therapy Site of Care Optimization (PDF)
• Inhaled Nitric Oxide Therapy (PDF)
• Intestinal and Multiviseral Transplant (PDF)
• Intradialytic Parenteral Nutrition/Intrperitoneal Amino Acid (IPAA Supplementation) (PDF)
• Intradiscal Electrothermal Therapy (IDET) Percutaneous Intradiscal Radiofrequncy Thermocoagulation (PDF)
• Intradiscal Steroid Injections for Pain Management (PDF)
• Intraperitoneal Hyperthermic Chemotherapy for Abdominopelvic Cancers (PDF)
• Investigational Procedure List (PDF)

J Policies

• no policies at this time

K Policies

• no policies at this time

L Policies

• Laser Therapy for Skin Conditions (PDF)
• Long Term Care Placement (PDF)
• Low-Frequency Ultrasound Therapy for Wound (PDF)
• Lung Transplantation (PDF)
• Lysis of Epidural Adhesions (PDF)

M Policies

• Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
• Microvolt T-Wave Alternans Testing (PDF)
• Multiple Sleep Latency Testing (PDF)

N Policies

• Neonatal Abstinence Syndrome Guideline (PDF)
• Neonatal Sepsis Management Guidelines (PDF)
• Neovascular (Wet) Macular Degeneration Treatment (PDF)
• Nerve Blocks for Pain Management (PDF)
• Neurofeedback (PDF)
• NICU Apnea Bradycardia Guidelines (PDF)
• NICU Discharge Guidelines (PDF)
• Nonmyeoablative Allogenic Transplant (PDF)
• Nutritional Therapy Oral and Enteral (PDF)

O Policies

• Obstetrical Home Health Programs (PDF)
• Occipital Nerve Stimulation for Headache (PDF)
• Optic Nerve Decompression Surgery (PDF)

P Policies

• Pancreas Transplant (PDF)
• Pannulectomy (PDF)
• Pediatric Heart Transplantation (PDF)
• Pediatric Liver Transplant (PDF)
• Percutaneous Left Atrial Appendage (Watchman) (PDF)
• Photophoresis (Extracorporeal Photochemotherapy) (PDF)
• Phototherapy and Photochemotherapy for Dermatological Conditions (PDF)
• Physical, Occupational and Speech Therapy (PDF)
• Plasmapheresis/Plasma Exchange/Therapeutic Apheresis (PDF)
• Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
• Prostatic Urethral Lift (PUL) (PDF)
• Proton and Neutron Beam Therapy (PDF)

Q Policies

• no policies at this time

R Policies

• Radial Head Implant (PDF)
• Radiation Therapy for Dupuytren's Contracture (PDF)
• Reduction Mammoplasty and Gynecomastia Surgery (PDF)
• Refractive Surgery (LASIK, LESEK, PRK, PARK and PRK-A) (PDF)

S Policies

• Sacroiliac Joint Fusion (PDF)
• Sacroiliac Joint Intervetions (PDF)
• Sclerotherapy for Varicose Veins (PDF)
• Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)
• Selective Nerve Root Blocks (PDF)
• Sickle Cell Disease Observation (PDF)
• Spinal Cord Stimulation (PDF)
• Stereotactic Body Radiation Therapy (PDF)

T Policies

• Tandem Transplant (PDF)
• Testing for Drugs of Abuse (PDF)
• Testing for Rupture of Fetal Membranes (PDF)
• Testing Select GU Conditions (PDF)
• Thyroid and Insulin Testing in Pediatrics (PDF)
• Total Artificial Heart (PDF)
• Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
• Transcranial Magnetic Stimulation (TMS) (PDF)
• Transcatheter Closure of Patent Foramen Ovale (PDF)
• Trigger Point Injections (PDF)

U Policies

• Ultrafiltration for Heart Failure (PDF)
• Ultrasound in Pregnancy (PDF)
• Umbilical Cord Blood Storage (PDF)
• Urinary Incontinence Devices and Treatments (PDF)
• Urodynamic Testing (PDF)

V Policies

• Vagus Nerve Stimulation (PDF)
• Ventricular Assist Devices (PDF)
• Ventriculectomy and Cardiomyoplasty (PDF)
• Video EEG (PDF)
• Vitamin D, Measurement of Serum (PDF)
• Vitamin D Testing in Pediatric Population (PDF)
• Voice Therapy (PDF)

W Policies

• Wheelchair Seating (PDF)
• Wireless Motility Capsule (PDF)

X Policies

• no policies at this time

Y Policies

• no policies at this time

Z Policies

• Zika Virus Testing (PDF)

Preventive Health Guidelines

• Adult Immunization Schedule
• 2021 Adult Preventive Health Guidelines (PDF)
• Childhood and Adolescent Immunizations
• 2019 Pediatric Preventive Guidelines (PDF)

Clinical Practice Guidelines

• ADHD in Children (PDF)
• American Academy of Family Physicians: Low Back Pain
• Annals of Internal Medicine: Diagnosis and Treatment of Low Back Pain
• Clinical Practice Guidelines Grid (PDF)
• Substance Use Disorder Practice Guideline (PDF)

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