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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

01/01/2020
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

01/01/2020
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 11/01/2019

Gait Analysis

06/01/2019

Gender Affirming Interventions for Gender Dysphoria

01/01/2020
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

03/01/2020

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

03/01/2020

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

03/01/2020
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

04/01/2020

New and Emerging Medical Technologies and Procedures

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

05/01/2020
Non-Contact Ultrasound Treatments for Wounds 04/01/2020

Optical Coherence Tomography (OCT) of the Anterior Eye Segment

08/01/2019
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)

08/01/2019

Signal-Averaged Electrocardiography (SAECG)

07/01/2019

Sphenopalatine Ganglion Block for Headache and Pain

07/01/2019
Sublingual Immunotherapy as a Technique of Allergen Specific Therapy 01/01/2020

Surface Electromyography (SEMG) Including Paraspinal SEMG

06/01/2019
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