Archived Medical Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
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 Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
C
D
E
F
G
H
- Hospital Safety Beds
- Hyperthermic Intraperitoneal Chemotherapy
- Hyperthermic Intraperitoneal Chemotherapy
- Hyperthermic Intraperitoneal Chemotherapy
- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
- Hypoglossal Nerve Stimulation for the Treatment of OSA
I
- Implantable Pain Pump
- Implantable Pain Pump
- Implantable Pain Pump
- Implantable Spinal Cord Stimulator
- Implantable Spinal Cord Stimulator
- Implantable Spinal Cord Stimulator
- Inhaled Nitric Oxide
- Inhaled Nitric Oxide
- Insulin Infusion Pump
- Insulin Infusion Pump
- Insulin Infusion Pump
- Intraosseous Basivertebral Nerve Ablation
- Intraosseous Basivertebral Nerve Ablation
- Intraosseous Basivertebral Nerve Ablation
L
M
- Mechanical Stretching Devices
- Mechanical Stretching Devices
- Mechanical Stretching Devices
- Metabolic and Bariatric Surgery-Revision
- Metabolic and Bariatric Surgery: Revision
- Metabolic and Bariatric Surgery: Revision
- Metabolic Bariatric Surgery
- Metabolic Bariatric Surgery
- Metabolic Bariatric Surgery
- Myoelectric Lower Extremity Prosthetic Technology
- Myoelectric Lower Extremity Prosthetic Technology
- Myoelectric Lower Extremity Prosthetic Technology
N
- Negative Pressure Wound Therapy
- Negative Pressure Wound Therapy
- Negative Pressure Wound Therapy
- Neonatal Discharge Criteria
- Neonatal Discharge Criteria
- Neonatal Discharge Criteria
- Non-Emergency Facility to Facility Transfers
- Non-Emergency Facility to Facility Transfers
- Nutritional Supplements
- Nutritional Supplements
- Nutritional Supports
P
- Peripheral Nerve Blocks for Treatment of Pain
- Peripheral Nerve Blocks for Treatment of Pain
- Peripheral Nerve Stimulators for the Treatment of Pain
- Peripheral Nerve Stimulators for the Treatment of Pain
- Peripheral Nerve Stimulators for the Treatment of Pain
- Peroral Endoscopic Myotomy
- Peroral Endoscopic Myotomy
- Peroral Endoscopic Myotomy (POEM)
- Personal Emergency Response Systems
- Personal Emergency Response Systems
- Personal Emergency Response Systems
- Positive Airway Pressure Devices for Pulmonary Disorders
- Positive Airway Pressure Devices for Pulmonary Disorders
- Positive Airway Pressure Devices for Pulmonary Disorders Continued Rental
- ProACT Adjustable Continence Therapy
- ProACT Adjustable Continence Therapy
- ProACT Adjustable Continence Therapy
R
S
- Sacroiliac Joint Fusion
- Sacroiliac Joint Fusion
- Sacroiliac Joint Fusion
- Sacroiliac Joint Procedures
- Sacroiliac Joint Procedures
- Sacroiliac Joint Procedures
- Safety Beds
- Safety Beds
- Saphenous Vein Ablation, Adhesive Injection
- Saphenous Vein Ablation, Adhesive Injection
- Sinus & Maxillofacial CT
- Skin Substitutes
- Skin Substitutes
- Skin Substitutes
- Special Needs Car Seats
- Special Needs Car Seats
- Spinal Canal Magnetic Resonance Angiography (MRA)
- Standing Frames
- Standing Frames
- Standing Frames
T
- Temporomandibular Joint Disorder or Dysfunction (TMJD/TMD) Craniomandibular Jaw Disorder/Non-Surgical Treatment
- Temporomandibular Joint Disorder or Dysfunction (TMJD/TMD) Craniomandibular Jaw Disorder/Non-Surgical Treatment
- Temporomandibular Joint Disorder or Dysfunction (TMJD/TMD) Craniomandibular Jaw Disorder/Non-Surgical Treatment
- Transcranial Magnetic Stimulation for Treatment of Depression
- Transcranial Magnetic Stimulation for Treatment of Depression
- Transcranial Magnetic Stimulation for Treatment of Depression
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections