Regence Logos
Medical Policy

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


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