Medical Policies List

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

A

• Acupuncture Therapy
• Allergy Testing
• Allergy Treatment
• Allograft Procedures of the Knee
• Amevive
• Ampyra
• Antifungal Medications
• Antineoplaston Cancer Therapy
• Apheresis
• Autologous Cell Therapy
• Autologous Chondrocyte Implantation (ACI)
• Avastin for Oncologic Indications

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B

• Bariatric Surgery
• Biofeedback
• Bisphosphonates
• Blepharoplasty, Blepharoptosis, and Brow Lift
• Botox

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C

• Capsule Endoscopy
• Cerebral Perfusion Study
• Chelation Therapy
• Cimzia
• Coblation for Musculoskeletal Conditions
• Cochlear Implants and Bone Anchored Hearing Aids (BAHA)
• Computer Assisted Navigation
• Corneal Topography, Corneal Mapping, Keratography
• Coronary Calcium Screening
• Coronary Computed Tomographic Angiography (CCTA)
• Cranial Orthotic Device
• Craniosacral Therapy

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D

• Deep Brain Stimulation
• Disc Therapy, Intervertebral
• Disclaimer Language
• Discograms
• Ductal Lavage and Fiberoptic Ductoscopy

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E

• Enuresis Treatments
• Epidural Injections
• Erbitux - See Oncology Conditions, Medical Treatment of
• Erythropoietin
• External Counterpulsation
• Extracorporeal Shock Wave Therapy (ESWT)

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F

• Facet Joint Injections and Medial Branch Nerve Block
• Femoroacetabular Impingement Surgery

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G

• Gastroesophageal Reflux Disease Endoscopic Treatments
• Gene Expression Profiling for the Management of Breast Cancer
• Gleevec - See Oncology Conditions, Medical Treatment of
• Gonadotropin Releasing Hormone Agonists
• Growth Hormone for Adults
• Growth Hormone for Pediatrics

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H

• Heavy Metal Testing
• Hormone (Estrogen-Progestin) Supplements
• Hormone Supplements for Non-Contraceptive Use
• Human Granulocyte/Macrophage Colony Stimulating Factors
• Hyperbaric Oxygen Therapy

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I

• Implantable Infusion Pump for the Treatment of Chronic Intractable Pain
• Infertility Testing and Treatment
• Inflammatory Disease, Medication for
• Infrared Therapy
• Interferon
• Intervertebral Disc Therapy - See Disc Therapy, Intervertebral
• Interspinous Distraction Device
• Intracranial and Vertebral Artery Angioplasty and Stenting
• Intravenous Immunoglobulin Therapy (IVIG)
• Intravitreal (Eye) VEGF Inhibitor Injections
• Isotretinoin
• IVIG for Treatment of Repeated Spontaneous Abortion (RSA)

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J

• Joint Resurfacing

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L

• Laser Assisted Uvulopalatoplasty (LAUP)
• Laser Treatment for Psoriasis
• Light Box Phototherapy for Seasonal Affective Disorder
• Lung Volume Reduction Surgery

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M

• Magnetic Resonance Angiography (MRA)
• Magnetic Resonance Imaging of the Spine
• Magnetic Resonance Spectroscopy (MRS)
• Magnetoencephalography (MEG Scan)
• Medial Branch Neuroablation
• Microprocessor Controlled Lower Limb Prosthesis
• Morbid Obesity, Non-surgical

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N

• Negative Pressure Wound Therapy (NPWT) Pumps
• Neumega (Oprelvekin, Thrombopoietic Growth Factor)
• Non-Invasive Measurements of Heart Disease Risk
• Nplate

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O

• Occipital Nerve Block
• Oncology Conditions, Medical Treatment of
• Oral Appliance for the Treatment of Obstructive Sleep Apnea
• Orthotic Cranioplasty (Cranial Banding) - See Cranial Orthotic Device
• Osteogeneic (Bone) Stimulators

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P

• Percutaneous Lysis of Epidural Adhesions
• Percutaneous Vertebroplasty/Kyphoplasty
• PET Scan
• Photodynamic Therapy (Levulan, verteporfin, Visudyne)
• Physical Therapy, Occupational Therapy, and Lymphedema Therapy
• Platelet Injections for Tendonitis
• Prolia
• Prolotherapy
• Proton Beam Radiotherapy
• Provenge
• Psychological and Neuropsychological Testing
• Pulsed Dye Laser for Warts

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R

• Reduction Mammoplasty
• Remicade
• Restasis
• Revlimid - See Oncology Conditions, Medical Treatment of
• Rituxan
• Robotic Assisted Surgery

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S

• Sacroiliac Joint Injection
• Salivary Hormones
• Selective Internal Radiation Therapy (SIRT)
• Skin Lesions, Benign, including Warts and Lipomas
• Sleep Disorder Testing
• Spinal Cord Stimulators
• Sprycel - See Oncology Conditions, Medical Treatment of
• Stereotactic Radiosurgery (Gamma Knife)
• Sutent - See Oncology Conditions, Medical Treatment of
• Synagis

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T

• T-Wave Alternans Testing
• Tarceva - See Oncology Conditions, Medical Treatment of
• Tasigna - See Oncology Conditions, Medical Treatment of
• Temodar - See Oncology Conditions, Medical Treatment of
• Topical Retinoids
• Transmyocardial Revascularization (TMR)
• Trigger Point Injections
• Tykerb - See Oncology Conditions, Medical Treatment of
• Tysabri

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U

• Uterine Artery Embolization
• Uvulopalatopharyngoplasty (UPPP)

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V

• Vagus Nerve Stimulation for Intractable Epilepsy
• Varicose Vein Treatments
• Vectibix - See Oncology Conditions, Medical Treatment of
• Video Electroencephalogram (VEEG) Monitoring
• Virtual Colonoscopy
• Vision Therapy
• Votrient - See Oncology Conditions, Medical Treatment of

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W

• Wound Vac Therapy - See Negative Pressure Wound Therapy

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X

• Xolair

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