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Medical Policy

Medicine Section

Policy Name Date Modified
Actigraphy 02/01/2019
Auricular Electrostimulation 04/01/2018

Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions

01/01/2019
Automated Point-of-Care Nerve Conduction Studies 02/01/2019
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 01/01/2019
Cell Therapy for Peripheral Arterial Disease 01/01/2019
Charged-Particle (Proton) Radiotherapy 01/01/2019
Confocal Laser Endomicroscopy 09/01/2018
Corneal Collagen Cross-Linking 01/01/2019
Coverage of Treatments Provided in a Clinical Trial 01/01/2019

Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults

11/01/2018
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 11/01/2018

Gait Analysis

04/01/2018
Hyperbaric Oxygen Therapy (HBOT) 11/01/2018
Immunological Cellular Therapies and Gene Therapies 08/01/2018
In Vivo Analysis of Colorectal Polyps 11/01/2018
Ingestible pH and Pressure Capsule 02/01/2019

Intensity Modulated Radiotherapy (IMRT) for Central Nervous System (CNS) Tumors

01/07/2019

Intensity Modulated Radiotherapy (IMRT) of the Thorax

10/01/2018
Intensity Modulated Radiotherapy (IMRT) of the Abdomen and Pelvis 10/01/2018

Intensity Modulated Radiotherapy (IMRT) of the Head and Neck Cancers and Thyroid Cancer

10/01/2018

Intensity Modulated Radiotherapy (IMRT) of the Prostate

10/01/2018
Low-Level Laser Treatment of Neuromuscular Pain Disorders and Other Miscellaneous Conditions 10/01/2018
Measurement of Exhaled Breath Condensates in the Diagnosis and Management of Other Respiratory Disorders 02/01/2018
Neurofeedback 03/01/2018

New and Emerging Medical Technologies and Procedures

01/01/2019
Non-Contact Ultrasound Treatments for Wounds 04/01/2018

Optical Coherence Tomography (OCT) of the Anterior Eye Segment

08/01/2018
Orthopedic Applications of Stem Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow 01/01/2019
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia 01/01/2019
Prolotherapy 03/01/2018
Quantitative Sensory Testing 06/01/2018

Radioembolization for Primary and Metastatic Tumors of the Liver

02/01/2019

Signal-Averaged Electrocardiography (SAECG)

06/01/2018

Sphenopalatine Ganglion Block for Headache and Pain

02/01/2019
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy 12/01/2018
Suprachoroidal Delivery of Pharmacologic Agents 05/01/2018

Surface Electromyography (SEMG) Including Paraspinal SEMG

06/01/2018
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders 10/01/2018
Transcutaneous Electrical Modulation Pain Reprocessing 11/01/2018

Transgender Services

12/01/2018
Vertebral Axial Decompression 05/01/2018