Clinical Policies
A
- Acoustic cardiography/heart sound recording PDF
- Actigraphy PDF
- Acupuncture PDF
- Air ambulance transport PDF
- Altered auditory feedback devices for speech dysfluency (stuttering) PDF
- Ambulatory blood pressure monitoring PDF
- Ambulatory continuous peripheral nerve block for chronic pain PDF
- Apnea monitors for infants-in home use PDF
- Aquatic therapy PDF
- Art therapy PDF
- Artificial pancreas device system PDF
- Athletic pubalgia (sports hernia) surgery PDF
- Auricular stimulation for abdominal pain from irritable bowel syndrome PDF
- Autologous chondrocyte implantation PDF
- Automated scalp cooling PDF
B
- Balloon dilation of the Eustachian tube PDF
- Behavioral health weight management interventions for children with increased body mass index screenings PDF
- Biofeedback for chronic pain PDF
- Bioimpedance devices for detecting lymphedema PDF
- Blue Native polyacrylamide gel electrophoresis for mitochondrial myopathies PDF
- Bone graft substitutes PDF
- Bone marrow transplant for children with hyper IgM disorder PDF
- Botulinum toxin for constipation PDF
- Brachytherapy for cancers other than prostate PDF
- Breast pumps PDF
- Bronchial thermoplasty for severe asthma PDF
C
- Cardiac contractility modulation PDF
- Cecostomy for fecal incontinence PDF
- Cell-free DNA prenatal screening PDF
- Cervical cancer and human papillomavirus screening PDF
- Cervical traction devices for neck pain for home use PDF
- Chronic inflammatory response syndrome PDF
- Circulating tumor DNA and circulating tumor cells for cancer management (liquid biopsy) PDF
- Computer-aided detection and diagnosis for chest imaging PDF
- Computerized gait analysis PDF
- Core decompression for avascular necrosis of the hip PDF
- Corneal cross-linking PDF
- Coronary intravascular lithotripsy PDF
- Cosmetic and plastic reconstructive surgery PDF
- Cryopreservation of reproductive tissue, gametes, and embryos PDF
- Customized lymphedema garments PDF
D
- Dermabrasion and chemical peel PDF
- Digestive enzyme cartridge PDF
- Disposable insulin delivery devices PDF
- Donor human milk PDF
- Drug-eluting sinus implants PDF
- Dynamic movement orthoses (suit therapy) PDF
- Dynamic splinting PDF
E
- Electrical muscle stimulation PDF
- Embrace 2 watch for seizure detection. PDF
- Emerg Auto-Emersion Therapy system and Dolphin Fluid Immersion Simulation system for pressure injury PDF
- EndeavorRx video for ADHD PDF
- Endovenous stents. PDF
- Epidermal nerve fiber density testing PDF
- Equine-assisted therapy PDF
- Erectile dysfunction treatments other than pharmaceuticals PDF
- Erectile dysfunction treatments other than pharmaceuticals PDF
- Excimer laser for vitiligo PDF
- External counterpulsation therapy PDF
F
- Face transplantation PDF
- Familial polyposis gene testing PDF
- Fetal surgeries in utero PDF
- Flexitouch® pneumatic compression devices for lymphedema after head and neck surgery PDF
- Fluorescence in situ hybridization for cervical cancer screening PDF
- Fluorescence spectroscopy for prostate cancer diagnosis PDF
- Fundus photography PDF
G
- Gastrointestinal electrical stimulation for obesity PDF
- Gastroparesis evaluations PDF
- Genetic testing for Alzheimer’s disease PDF
- Genetic testing for Duchenne muscular dystrophy PDF
- Genetic testing for G1691A polymorphism factor V Leiden PDF
- Genetic testing for maple syrup urine disease PDF
H
- Hand and arm transplants PDF
- Hidradenitis suppurativa surgery PDF
- Home spirometry PDF
- Home uterine activity monitoring PDF
- Home-use light box therapy for seasonal affective disorder PDF
- Hydrogel spacer use during radiotherapy for prostate cancer PDF
- Hypoglossal nerve stimulation PDF
I
- IFuse implant system PDF
- Immune cell function assay PDF
- Inhaled nitric oxide PDF
- Injectable bulking agents — fecal incontinence PDF
- Intermittent pneumatic compression for peripheral artery disease PDF
- Intracranial hypertension stent PDF
- Intravascular ultrasound PDF
K
Back to top ↑L
- Laser thermal ablation for seizures refractory to medical management PDF
- Latera absorbable nasal implant PDF
- Lipoprotein apheresis PDF
- Low-frequency ultrasound therapy for wound management PDF
- Lung transplants PDF
M
- Manipulation under anesthesia (hip and elbow) PDF
- MarginProbe PDF
- Measurement of serum antibodies to Infliximab and Adalimumab PDF
- Medical alert devices PDF
- Medical three-dimensional printing PDF
- Melody™ transcatheter pulmonary valve replacement PDF
- Microwave thermotherapy for breast cancer PDF
- Microwave thermotherapy for lung and kidney tumors PDF
- Molecular analysis for targeted therapy of non-small cell lung cancer PDF
- Molecular analysis for targeted treatment for hepatobiliary cancer PDF
- Molecular analysis for treatment of primary brain tumors PDF
- Myocardial strain imaging PDF
N
Back to top ↑O
Back to top ↑P
- Pancreas transplantation PDF
- Pediatric bed enclosures and sensory beds PDF
- Pediatric intensive feeding programs PDF
- Pediatric rhinoplasty PDF
- Pediatric turbinectomy and turbinoplasty PDF
- Percutaneous arteriovenous fistula creation using EverlinQ and Ellipsys techniques PDF
- Percutaneous sacroplasty PDF
- Peripheral nerve stimulators for chronic nerve pain PDF
- Peristeen® anal irrigation system PDF
- Peroral endoscopic myotomy PDF
- Pet therapy PDF
- Phototherapy and photochemotherapy for skin conditions PDF
- Phrenic (diaphragmatic) nerve stimulation PDF
- Platelet rich plasma PDF
- Port-wine stain and infantile hemangioma treatment PDF
- Postural orthostatic tachycardia syndrome treatment with physical therapy PDF
- Prescription digital therapeuticss for contraception PDF
- Prolotherapy PDF
- Prostatic urethral lift/UroLift for benign prostatic hypertrophy PDF
R
- Radiofrequency ablation for nasal valve collapse PDF
- Radiofrequency ablation of genicular nerves for knee pain PDF
- Re-SET-O PDF
- Renal denervation PDF
- Robotic orthoses – lower limb PDF
- Robotic orthoses – upper limb PDF
- Room humidifiers PDF
S
- Sacral nerve modulation/stimulation PDF
- Scoliosis vertebral body tethering and stapling PDF
- Serum proteomic cancer risk classification of indeterminate pulmonary nodules PDF
- Shoe lifts for leg length discrepancy PDF
- Sialendoscopy and lithotripsy for salivary stones PDF
- Skin surgery after massive weight loss PDF
- Smell and taste dysfunction testing PDF
- Somryst digital therapy for insomnia PDF
- Specialized infant formula PDF
- Speech therapy PDF
- Sphenopalatine ganglion block injections for headache PDF
- Supraglottoplasty and laryngoplasty PDF
T
- Tactile breast imaging PDF
- Telebehavioral health PDF
- Therapeutic contact lenses PDF
- Three-dimensional imaging and interpretation PDF
- Topical oxygen therapy PDF
- Total artificial heart PDF
- Transanal radiofrequency for fecal incontinence PDF
- Transcatheter coronary infusion of supersaturated oxygen therapy in acute myocardial infarction PDF
V
- Vaginitis diagnostic testing PDF
- Vagus nerve stimulation for post-stroke upper limb rehabilitation PDF
- Vestibular evoked myogenic potential testing PDF
- Video head impulse testing PDF
- Virtual colonoscopy – CT colonography PDF
- Vitamin D screening PDF
- Volatile organic compounds for urinary tract infection PDF
W
- Wearable dialysis and implantable artificial kidneys PDF
- Wheelchair mounted robotic arm – Kinova Jaco2 PDF
- Whole genome, mitochondrial genome, and exome sequencing PDF
- Wireless pulmonary artery pressure monitoring devices for heart failure PDF
