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Medicine Section

Policy Name	Policy ID Number	Date Modified
Actigraphy	MED125	12/01/2023
Auricular Electrostimulation	MED146	05/01/2023
Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions	MED77	01/01/2024
Automated Point-of-Care Nerve Conduction Studies	MED128	03/01/2024
Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products	MED170	04/01/2024
Cardiac Hemodynamic and Thoracic Fluid Index Monitoring for the Management of Heart Failure in the Outpatient Setting	MED33	08/01/2023
Cell Therapy for Peripheral Arterial Disease	MED141	01/01/2024
Charged-Particle (Proton) Radiotherapy	MED49	10/01/2023
Confocal Laser Endomicroscopy	MED151	11/01/2023
Coverage of Treatments Provided in a Clinical Trial	MED150	02/01/2024
Digital Therapeutic Products	MED175	10/01/2023
Digital Therapeutic Products for Amblyopia	MED175.04	10/01/2023
Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder	MED175.01	11/01/2023
Digital Therapeutic Products for Chronic Low Back Pain	MED175.03	11/01/2023
Digital Therapeutic Products for Post-traumatic Stress Disorder and Panic Disorder	MED175.05	02/01/2024
Digital Therapeutic Products for Substance Use Disorders	MED175.02	11/01/2023
Dry Needling	MED39	03/01/2024
Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults	MED152	12/01/2023
Extracorporeal Shock Wave Therapy (ESWT)	MED90	01/01/2024
Gender Affirming Interventions for Gender Dysphoria	MED153	04/01/2024
Hyperbaric Oxygen Therapy	MED14	12/01/2023
Hyperoxemic Reperfusion Thearpy	MED173	09/01/2023
Immunological Cellular Therapies and Gene Therapies	MED42	07/01/2023
In Vivo Analysis of Colorectal Lesions	MED104	02/01/2024
Ingestible pH and Pressure Capsule	MED117	12/01/2023
Intensity Modulated Radiotherapy (IMRT) for Breast Cancer	MED166	01/01/2024
Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk	MED167	01/01/2024
Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS), Head, Neck, and Thyroid	MED164	04/01/2024
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities	MED165	04/01/2024
Laser Interstitial Thermal Therapy	MED177	04/01/2024
Low-Level Laser Therapy	MED105	01/01/2024
Manipulation Under Anesthesia	MED130	02/01/2024
Measurement of Exhaled Breath Condensates in the Diagnosis and Management of Other Respiratory Disorders	MED108	03/01/2024
Myocardial Strain Imaging	MED168	04/01/2024
Neurofeedback	MED65	11/01/2023
New and Emerging Medical Technologies and Procedures	MED149	01/01/2024
Non-Contact Ultrasound Treatments for Wounds	MED131	04/01/2024
Optical Coherence Tomography (OCT) of the Anterior Eye Segment	MED133	09/01/2023
Orthopedic Applications of Stem Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow	MED142	01/01/2024
Periurethral Transperineal Adjustable Balloon Continence Device	MED176	01/01/2024
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia	MED100	12/01/2023
Prolotherapy	MED40	05/01/2023
Quantitative Sensory Testing	MED91	09/01/2023
Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE)	MED140	04/01/2024
Signal-Averaged Electrocardiography (SAECG)	MED21	06/01/2023
Skin Lesion Imaging and Spectroscopy	MED174	11/01/2023
Sphenopalatine Ganglion Block for Headache and Pain	MED160	09/01/2023
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy	MED121	02/01/2024
Targeted Phototherapy for the Treatment of Psoriasis	MED98	03/01/2024
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders	MED148	01/01/2024
Transcutaneous Electrical Modulation Pain Reprocessing	MED143	01/01/2024
Treatment of Adult Sepsis	MED172	10/01/2023
Vertebral Axial Decompression	MED45	05/01/2023
Vestibular Evoked Myogenic Potential Testing	MED169	03/01/2024
Whole Body Hyperthermia	MED15	10/01/2023


	The Blue Cross and/or Blue Shield Plans comprising The Regence Group serve Idaho, Oregon, Utah and much of Washington state. The Regence Group and each of its affiliate Plans are independent licensees of the Blue Cross and Blue Shield Association.