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Medical Policy

Medicine Section

Policy Name Date Modified
Actigraphy 02/01/2020
Auricular Electrostimulation 04/01/2020

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

Automated Point-of-Care Nerve Conduction Studies 04/01/2020
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 06/01/2019
Cell Therapy for Peripheral Arterial Disease 02/01/2020
Charged-Particle (Proton) Radiotherapy 10/01/2019
Confocal Laser Endomicroscopy 10/01/2019
Coverage of Treatments Provided in a Clinical Trial 02/01/2020

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

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 11/01/2019

Gait Analysis


Gender Affirming Interventions for Gender Dysphoria

Hyperbaric Oxygen Therapy 11/01/2019
Immunological Cellular Therapies and Gene Therapies 11/01/2019
In Vivo Analysis of Colorectal Polyps 02/01/2020
Ingestible pH and Pressure Capsule 02/01/2020
Intensity Modulated Radiotherapy (IMRT) for Breast Cancer 03/01/2020

Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk


Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS), Head, Neck, and Thyroid


Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, and Pelvis

Policy Version Effective 06/1/2020:
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities

Low-Level Laser Treatment of Neuromuscular Pain Disorders and Other Miscellaneous Conditions 09/01/2019
Measurement of Exhaled Breath Condensates in the Diagnosis and Management of Other Respiratory Disorders 04/01/2020

Myocardial Strain Imaging


New and Emerging Medical Technologies and Procedures

Policy Version Effective 08/01/2020:
New and Emerging Medical Technologies and Procedures

Non-Contact Ultrasound Treatments for Wounds 04/01/2020

Optical Coherence Tomography (OCT) of the Anterior Eye Segment

Orthopedic Applications of Stem Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow 02/01/2020
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia 02/01/2020
Prolotherapy 04/01/2020
Quantitative Sensory Testing 06/01/2019

Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE)


Signal-Averaged Electrocardiography (SAECG)


Sphenopalatine Ganglion Block for Headache and Pain

Sublingual Immunotherapy as a Technique of Allergen Specific Therapy 01/01/2020

Surface Electromyography (SEMG) Including Paraspinal SEMG

Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders 01/01/2020
Transcutaneous Electrical Modulation Pain Reprocessing 02/01/2020
Vertebral Axial Decompression 07/01/2019