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Medicine Section

Policy Name	Date Modified
Acoustic Cardiography	12/01/2012
Actigraphy	01/01/2013
Auricular Electrostimulation	05/01/2013
Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions 7/1/2013 Effective Policy: Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions	02/01/2013
Automated Point-of-Care Nerve Conduction Studies	03/01/2013
Breast Duct Endoscopy (Ductoscopy)	08/01/2012
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting	07/01/2012
Charged Particle (Proton or Helium Ion) Radiation Therapy	10/01/2012
Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease	12/01/2012
Enhanced External Counterpulsation (EECP)	08/01/2012
Epiretinal Radiation Therapy for Age-Related Macular Degeneration	09/01/2012
Epithelial Cell Cytology in Breast Cancer Risk Assessment and High Risk Patient Management (Ductal Lavage and Suction Collection Systems)	09/17/2012
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions	03/01/2013
Gait Analysis	06/01/2013
Hyperbaric Oxygen Pressurization (HBO)	05/23/2013
In Vivo Analysis of Colorectal Polyps	01/01/2013
Ingestible pH and Pressure Capsule	01/01/2013
Intensity Modulated Radiation Therapy (IMRT): Central Nervous System (CNS) and Vertebral Tumors	12/01/2012
Intensity Modulated Radiation Therapy (IMRT) of the Abdomen and Pelvis	12/01/2012
Intensity Modulated Radiation Therapy (IMRT) of the Head and Neck Cancers and Thyroid Cancer	12/01/2012
Intensity Modulated Radiation Therapy (IMRT) of the Prostate	12/11/2012
Intensity Modulated Radiation Therapy (IMRT) of the Thorax (Breast, Esophageal, and Lung Cancer and Malignant Pleural Mesothelioma)	12/01/2012
Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation	01/01/2013
Low Level Laser Treatment of Neuromuscular Pain Disorders and Other Miscellaneous Conditions	09/01/2012
Manipulation Under Anesthesia for the Treatment of Pain	09/17/2012
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensates in the Diagnosis and Management of Patients with Asthma and Other Respiratory Disorders	04/01/2013
Microwave Thermotherapy for Primary Breast Cancer	09/17/2012
Neurofeedback	04/01/2013
Non-Contact Ultrasound Treatments for Wounds	05/01/2013
Optical Coherence Tomography (OCT) of the Anterior Eye Segment	09/17/2012
Orthopedic Applications of Stem-Cell Therapy	03/01/2013
Outpatient Cardiac Telemetry	01/01/2013
Outpatient Intravenous Insulin Therapy (OIVIT)	11/01/2012
Paraspinal Surface Electromyography (EMG) to Evaluate and Monitor Back Pain	01/01/2013
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia	01/01/2013
Prolotherapy	04/01/2013
Quantitative Sensory Testing	08/01/2012
Radioembolization for Primary and Metastatic Tumors of the Liver	10/01/2012
Research Urgent Treatments	11/01/2012
Retinal Prosthesis	08/01/2012
Signal-Averaged Electrocardiography (SAECG)	08/01/2012
Stem-cell Therapy for Peripheral Arterial Disease	01/01/2013
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy	06/01/2013
Suprachoroidal Delivery of Pharmacologic Agents	06/01/2013
Temporary Prostatic Stent	09/01/2012
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders	06/01/2013
Transcutaneous Electrical Modulation Pain Reprocessing	01/01/2013
T-Wave Alternans	09/01/2012
Vertebral Axial Decompression	06/01/2013


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