Clinical Policies

Navigate directly to a letter:

A
B
C
D
E
F
G
H
I
K
L
M
N
O
P
R
S
T
U
V
W
X
Z

A
- Acoustic cardiography/heart sound recording
- Actigraphy
- Acupuncture
- Air ambulance transport
- Altered auditory feedback devices for speech dysfluency (stuttering)
- Ambulatory blood pressure monitoring
- Ambulatory continuous peripheral nerve block for chronic pain
- Apnea monitors for infants-in home use
- Aquatic therapy
- Art therapy
- Artificial pancreas device system
- Athletic pubalgia (sports hernia) surgery
- Auricular Stimulation for Abdominal Pain From Irritable Bowel Syndrome
- Autologous chondrocyte implantation
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B
- Balloon dilation of the Eustachian tube
- Behavioral health weight management interventions for children with increased body mass index screenings
- Biofeedback for chronic pain
- Bioimpedance devices for detecting lymphedema
- Blue Native polyacrylamide gel electrophoresis for mitochondrial myopathies
- Bone graft substitutes
- Bone marrow transplant for children with hyper IgM disorder
- Botulinum toxin for constipation
- Brachytherapy
- Breast Pumps
- Bronchial Thermoplasty for Severe Asthma
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C
- Cardiac contractility modulation
- Cecostomy for fecal incontinence
- Cell-free DNA prenatal screening
- Cervical Traction Devices for Neck Pain for Home Use
- Cervical cancer and human papillomavirus screening
- Chronic inflammatory response syndrome
- Computer-aided detection and diagnosis for chest imaging
- Computerized gait analysis
- Core decompression for avascular necrosis of the hip
- Corneal cross-linking
- Coronary intravascular lithotripsy
- Cosmetic and plastic reconstructive surgery
- Cryopreservation of reproductive tissue, gametes, and embryos
- Customized lymphedema garments
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D
- Dermabrasion and chemical peel
- Digestive enzyme cartridge
- Disposable insulin delivery devices
- Donor human milk
- Dynamic Splinting
- Dynamic movement orthoses (suit therapy)
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E
- Electrical muscle stimulation
- Embrace 2 watch for seizure detection
- Emerg Auto-Emersion Therapy System and Dolphin Fluid Immersion Simulation System for Pressure Injury
- Endobronchial Valve Placement
- Endovenous stents.
- EpiSign Testing for DNA Methylation Analysis
- Equine-assisted therapy
- Erectile dysfunction treatments other than pharmaceuticals
- Excimer laser for vitiligo
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F
- Face transplantation
- Fetal Surgeries In Utero
- Flexitouch® pneumatic compression devices for lymphedema after head and neck surgery
- Fluorescence in situ hybridization for cervical cancer screening
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G
- Gastrointestinal electrical stimulation for obesity
- Gastroparesis Evaluations
- Genetic testing for Alzheimer’s disease
- Genetic testing for Duchenne muscular dystrophy
- Genetic testing for maple syrup urine disease
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H
- Hand and arm transplants
- Hidradenitis Suppurativa Surgery
- Home spirometry
- Home uterine activity monitoring
- Home-use Light Box Therapy for Seasonal Affective Disorder
- Hydrogel spacer use during radiotherapy for prostate cancer
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I
- Immune Cell Function Assays in Transplantation
- Inhaled nitric oxide
- Injectable bulking agents — fecal incontinence
- Intermittent pneumatic compression for peripheral artery disease
- Intracranial hypertension stent
- Intravascular ultrasound
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K
- Ketone monitor for ketogenic diet in epilepsy
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L
- Laser thermal ablation for seizures refractory to medical management
- Latera Absorbable Nasal Implant
- Lipoprotein apheresis
- Low-frequency ultrasound therapy for wound management
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M
- Manipulation under anesthesia (hip and elbow)
- MarginProbe
- Measurement of serum antibodies to Infliximab and Adalimumab
- Medical Alert Devices
- Medical three-dimensional printing
- Microwave thermotherapy for breast cancer
- Microwave thermotherapy for lung and kidney tumors
- Molecular analysis for targeted therapy of non-small cell lung cancer
- Molecular analysis for targeted treatment for hepatobiliary cancer
- Myocardial strain imaging
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N
- Neuroablation for chronic foot pain
- Non cosmetic abdominoplasty
- Non-Wheelchair Adaptive Seating
- Nonpharmacologic treatments for chronic vertigo
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O
- Oral nutritional supplements
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P
- Pancreas transplantation
- Pediatric Intensive Feeding Programs
- Pediatric Turbinoplasty
- Pediatric bed enclosures
- Pediatric rhinoplasty
- Percutaneous arteriovenous fistula creation
- Percutaneous peripheral nerve stimulators for chronic nerve pain
- Percutaneous sacroplasty
- Peristeen® anal irrigation system
- Peroral endoscopic myotomy
- Pet therapy
- Phototherapy and photochemotherapy for skin conditions
- Phrenic (diaphragmatic) nerve stimulation
- Platelet rich plasma for nonhealing diabetic wounds
- Port-wine stain and infantile hemangioma treatment
- Postural orthostatic tachycardia syndrome treatment with physical therapy
- Prescription digital therapeutics for attention deficit hyperactivity disorder
- Prescription digital therapeutics for insomnia
- Prescription digital therapeuticss for contraception
- Prolotherapy
- Prostatic urethral lift/UroLift for benign prostatic hyperplasia
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R
- RESET-O
- Radiofrequency ablation for nasal valve collapse
- Radiofrequency ablation of genicular nerves for knee pain
- Renal denervation
- Robotic orthoses – lower limb
- Robotic orthoses – upper limb
- Room humidifiers
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S
- Sacral nerve modulation/stimulation
- Scoliosis vertebral body tethering and stapling
- Serum proteomic cancer risk classification of indeterminate pulmonary nodules
- Shoe Lifts for Leg Length Discrepancy
- Sialendoscopy and lithotripsy for salivary stones
- Site of Care Medical Pharmacy
- Skin Substitutes for Chronic Wounds
- Skin surgery after massive weight loss
- Smell and taste dysfunction testing
- Specialized infant formula
- Speech therapy
- Sphenopalatine ganglion block injections for headache
- Stereotactic navigation in sinus surgery
- Subacromial balloon spacer implantation in massive irreparable rotator cuff tears
- Supraglottoplasty and Laryngoplasty
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T
- Tactile breast imaging
- Therapeutic Contact Lenses
- Three-dimensional imaging and interpretation
- Topical oxygen therapy
- Total artificial heart
- Transanal radiofrequency for fecal incontinence
- Transcatheter Therapy for Severe Ticuspid Insufficiency
- Transcatheter coronary infusion of supersaturated oxygen therapy in acute myocardial infarction
- Transcatheter pulmonary valve replacement
- Transperineal laser ablation of the prostate for benign prostatic hyperplasia
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U
- Use of autologous fat grafting and injectable soft-tissue fillers for reconstructive and therapeutic purposes
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V
- Vaginitis Diagnostic Testing
- Vagus nerve stimulation for post-stroke upper limb rehabilitation
- Vestibular evoked myogenic potential testing
- Video head impulse testing
- Vitamin D screening
- Volatile organic compounds for urinary tract infection
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W
- WATS-3D brush biopsy for Barrett’s esophagus
- Wearable dialysis and implantable artificial kidneys
- Wheelchair mounted robotic arm – Kinova Jaco2
- Whole genome, mitochondrial genome, and exome sequencing
- Wireless pulmonary artery pressure monitoring devices for heart failure
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X
- Xen gel stent for glaucoma
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Z
- ZOLL Heart Failure Management System
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