Archived Medical Policies

The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.

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  A

  • Abortion
  • Adaptive Equipment
  • Adaptive Equipment
  • Adult Developmental Day Treatment
  • Adult Developmental Day Treatment Services
  • Adult Developmental Day Treatment Services
  • Adult Developmental Day Treatment Services
  • Airway Clearance Devices
  • Applied Behavior Analysis for Autism Spectrum Disorder
  • Applied Behavior Analysis for Autism Spectrum Disorder
  • Applied Behavior Analysis for Autism Spectrum Disorder
  • Applied Behavior Analysis for Autism Spectrum Disorder
  • Applied Behavior Analysis for Autism Spectrum Disorder

  B

  • Breast Cancer Index (BCI) for Managing Breast Cancer Treatment
  • Breast Cancer Index (BCI) for Managing Breast Cancer Treatment
  • Breast Cancer Index® (BCI) for Managing Breast Cancer Treatment
  • Breast Reduction Surgery

  C

  • Continuous Glucose Monitoring (CGM)
  • Continuous Glucose Monitors
  • Continuous Glucose Monitors

  D

  • Drug Testing
  • Drug Testing
  • Drug Testing

  E

  • Early Intervention Day Treatment (EIDT)
  • Early Intervention Day Treatment (EIDT)
  • Early Intervention Day Treatment (EIDT)
  • Early Intervention Day Treatment (EIDT)
  • Environmental Modification Services
  • Environmental Modification Services
  • Epidural Steroid Injections
  • Epidural Steroid Injections
  • Epidural Steroid Injections

  F

  • Facet Joint Interventions
  • Facet Joint Interventions
  • Fraction Flow Reserve from computer tomography (FFRct)
  • Fraction Flow Reserve from computer tomography (FFRct)
  • Fraction Flow Reserve from Computer Tomography (FFRct)
  • Fraction Flow Reserve from Computer Tomography (FFRct)

  G

  • Genetic Testing and Counseling
  • Genetic Testing and Counseling
  • Genetic Testing and Counseling
  • Genetic Testing and Counseling
  • Genetic Testing and Counseling

  H

  • Hospital Safety Beds

  I

  • Implantable Pain Pump
  • Implantable Pain Pump
  • Implantable Spinal Cord Stimulator
  • Implantable Spinal Cord Stimulator
  • Intensive In-Home (IIH) Services
  • Intensive In-Home (IIH) Services
  • Intensive In-Home (IIH) Services
  • Intraosseous Basivertebral Nerve Ablation
  • Intraosseous Basivertebral Nerve Ablation
  • Intraosseous Basivertebral Nerve Ablation

  M

  • Mechanical Stretching Devices
  • Mechanical Stretching Devices
  • Mechanical Stretching Devices
  • Metabolic and Bariatric Surgery in Adults Ages 18 to 65
  • Metabolic and Bariatric Surgery Revision
  • Metabolic and Bariatric Surgery Revision
  • Metabolic and Bariatric Surgery-Revision
  • Metabolic and Bariatric Surgery: Revision
  • Metabolic Bariatric Surgery
  • Metabolic Bariatric Surgery
  • Metabolic Bariatric Surgery
  • Metabolic Bariatric Surgery

  N

  • Negative Pressure Wound Therapy
  • Negative Pressure Wound Therapy
  • Negative Pressure Wound Therapy (NPWT)
  • Negative Pressure Wound Therapy (NPWT)
  • Negative Pressure Wound Therapy (NPWT)
  • Noninvasive Home Mechanical Ventilation
  • Nutritional Supplements – Commercial Thickeners Administered Orally

  P

  • Peripheral Nerve Stimulators for Treatment of Pain
  • Positive Airway Pressure Devices for Pulmonary Disorders Continued Rental
  • Private Duty Nursing

  R

  • Radiofrequency and Microwave Ablation of Tumors
  • Radiofrequency and Microwave Ablation of Tumors
  • Radiofrequency and Microwave Ablation of Tumors
  • Rehabilitative Services for Persons with Physical Disabilities
  • Rehabilitative Services for Persons with Physical Disabilities
  • Rehabilitative Services for Persons with Physical Disabilities
  • Rehabilitative Services for Persons with Physical Disabilities

  S

  • Sacroiliac Joint Fusion
  • Sacroiliac Joint Fusion
  • Sacroiliac Joint Procedures
  • Sacroiliac Joint Procedures
  • Sacroiliac Joint Procedures
  • Safety Beds
  • Safety Beds
  • Safety Beds
  • Saphenous Vein Ablation, Adhesive Injection
  • Saphenous Vein Ablation, Adhesive Injection
  • Saphenous Vein Ablation, Adhesive Injection
  • Skin Substitutes
  • Skin Substitutes
  • Skin Substitutes
  • Special Needs Car Seats
  • Special Needs Car Seats
  • Special Needs Car Seats
  • Standing Frames
  • Standing Frames
  • Standing Frames
  • Supportive Living Services
  • Supportive Living Services

  T

  • Trigger Point Injections
  • Trigger Point Injections