Medical Policies

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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

• Abortion: see Termination of Pregnancy, Elective - 91000
  
• Abortion, Recurrent Spontaneous - 91156
• Allergy Testing/Immunotherapy - 91037
• Apnea Monitors - 91497 Updated 07/01/08
• Artificial Intervertebral Discs - 91493 Reviewed 8/08
• Assisted Reproduction/Artificial Conception: See Infertility Diagnosis & Treatment/Assisted Reproduction/Artificial Conception
• Augmentative Communications / Speech-Generating Devices for Medicaid Members - 91499
• Augmentative Communication Device PA form (Medicaid only) (117KB PDF)
  
• Autologous Chondrocyte Implant/Meniscal Allograft - 91443
• Automated Percutaneous Lumbar Discectomy - 91519 Reviewed 8/08
  
• Autopsy - 91054
• AxialIF^TM Axial Lumbar Interbody Fusion - 91549 New 3/20/08
  

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B

• Bariatric Surgery: See Obesity - 91435
• Biofeedback - 91002
• Blepharoptosis/Brow Ptosis Repair - 91376
• Blood Pressure Monitors for Medicaid Members - 91503
• Bone Density Studies - 91494 Updated 11/1/08 to remove bone mineral densitometry studies, for which see AIM Guidelines (127KB PDF).
• Bone Marrow/Peripheral Stem Cell or Blood Cell Transplantation - 91066
• Botulinum Toxin - 91455
• Breast Related Procedures - 91545 - Updated 8/20/08
• Bilateral Reduction Mammoplasty PA form

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C

• Capsule Endoscopy - 91476  Updated 6/18/08
• Cardiac Loop Recorder, Implantable - 91496
• Cardioverter Defibrillators - 91410  Updated 9/19/08
• Implantable Cardioverter Defibrillator (ICD) PA form
• Carotid and Intracranial Artery Stenting - 91495 Updated 9/1/2008
• Carotid Artery Stenting with Embolic Protection System PA form (127KB PDF)
  
• Catheter Ablation for Cardiac Arrhythmias - 91314 Updated 04/08
  
• Chelation Therapy - 91077
• Cingulotomy - 91475
• Clinical Trials for Cancer Care - 91448 Reviewed 8/08
• Colorectal Cancer Screening - 91547 New 04/23/08
  
• Complications to Non-Covered Care - 91086
• Contact Lenses/Eyeglasses - 91425
• Continuous Glucose Monitoring - 91466 - 8/20/08
• Updated 8/20/08: Continuous Glucose Monitoring System PA form (38KB PDF)
  
• Coronary artery calcium score / EBCT: Policy removed. See AIM guidelines (127KB PDF).
• Coronary CT angiography: Policy removed. See AIM guidelines (127KB PDF).
• Cosmetic and Reconstructive Surgery Procedures - 91535
  
• Cranial Helmets - 91504 Reviewed 8/08
• Craniosacral Therapy - 91095

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D

• Dental Extractions - 91523 Updated 2/15/2008
  
• Detoxification - 91104
• NEW Dialectical Behavior Therapy (DBT) - 91555  Effective 1/1/2009
  
• Discectomy, Automated Percutaneous Lumbar - 91519
• Durable Medical Equipment - 91110 Updated 07/01/08

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E

• Eating Disorders - 91007  Updated 8/20/08
• NEW  Electro-convulsive Therapy (ECT) - 91554  Issued 10/20/2008
• Enclosed Bed Systems for Medicaid Members - 91498
• End Stage Renal Disease - 91526
• Endometrial Ablation Procedures for Menorrhagia - 91539 Updated 2/15/2008
  
• Endoscopic Treatment of GERD - 91483
• Enhanced External Counterpulsation (EECP) - 91440
• Enteral Nutritional Therapy - 91278
• Enteral formulas PA form (37KB PDF)
• Enteral formulas PA form - Medicare (389KB PDF)
• Enuresis Therapy - 91418
• Exceptional Cases - 91406
• Experimental/Investigational/Unproven Care - 91117 Updated 10/20/2008
  
• Extracorporeal Immunoadsorption (ECI) - 91118 Reviewed 10/20/2008
  
• Extracorporeal Shock Wave Therapy (ECWT) - 91527

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F

• Facial Scar Revisions - 91442
• Feeding Disorders - 91469  Reviewed 10/20/2008
  
• Female Erectile Dysfunction Therapy: see Sexual Dysfunction policy - 91160
• Fetal Surgery - 91120
• Fluocinolone Implant - 91511
• Foot Care - 91121

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G

• Genetic Counseling, Testing and Screening - 91540 Reviewed 8/08
• Breast and Ovarian Cancer Screening by Molecular Testing PA form (219KB PDF)
  
• Breast Cancer Treatment Assessment with Oncotype DX^TM PA form (195KB PDF)
  
• Growth Hormone Replacement in Adults - 91441
• Growth Hormone Therapy in Children - 91460 Reviewed 8/08

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H

• Hearing Augmentation - 91544 Reviewed 8/08
• Hip Resurfacing, Total - 91530  Updated 2/15/2008
  
• Home Care - 91023
• Home Hemodialysis - 91512  Updated 10/20/2008
  Updates: Page 2, section E, language change for further clarification; Page 1, section A, no. 5 from previous policy deleted
  
• Home Prothrombin Time or INR Monitoring - 91507 Updated 07/01/08
• Hospice Care - 91520 Reviewed 8/08
• Hyperbaric Oxygen Therapy - 91151
• Hyperhidrosis - 91451

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I

• IDET - 91438 Updated 07/01/08
• Implantable Cardioverter Defibrillator (ICD): See Cardioverter Defibrillator
• Impotence: See Sexual Dysfunction policy - 91160
  
• Incontinence Supplies for Medicaid Members - 91502
• Infertility Diagnosis and Treatment/Assisted Reproduction/Artificial Conception - 91163 Updated 6/18/08
• Infusion Pumps--Implantable and External - 91414  Updated 10/20/2008
  Updates: Page 2, section II, C, No. 1: Language added regarding prescribing physician
  
• Intranasal Flu Vaccine - 91480  Reviewed 10/20/2008
  
• NEW  Intraoperative Radiotherapy - 91556  Issued 10/20/2008
  
• Intraperitoneal Hyperthermic Chemotherapy - 91548 (new effective 3/20/08)
  
• Intravascular Brachytherapy - 91536
  
• Intravenous Immunoglobulin (IVIG) - 91514 (updated 9/19/2008)
• IVIG PA form (56KB PDF)
  

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J

K

L

• Levonorgestrel-Releasing IUD (Mirena®) IUD - 91487 Reviewed 8/2008
• Lipoprotein Testing - 91454
• Lung Volume Reduction Surgery - 91472  Reviewed 10/20/2008

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M
`

• MRI of the breast: Policy removed. See AIM guidelines (127KB PDF).
• Medical Necessity Determination - 91447
• Monochromatic Phototherapy (Anodyne Therapy/MIRE Therapy/Low Level Light Therapy) - 91486 Updated 6/18/08

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N

• Neocate: see Enteral Nutrition Therapy - 91278
  
• Neuropsychological and Psychological Testing - 91537 Updated 7/1/2008
  
• Never Events/Medical Errors - 91516
  Also see the pending policy to become effective 12/22/2008, which includes an updated list of hospital-acquired conditions for which additional payments are withheld, and reporting requirements.
• Non-Acute Inpatient Services - 91332   Reviewed 10/20/2008
  

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O

• Obesity - 91435 Updated 07/01/08
  • Bariatric Surgery Evaluation Authorization form (56KB PDF)
  • Bariatric Surgery Authorization Form (30KB PDF)
  • Medical Weight Loss Program PA form (129KB PDF)
    
• Obstructive Sleep Apnea & Upper Airway Resistance Syndrome - 91333 Updated 9/1/2008
• Oral Surgery - 91542 Updated 2/15/2008
  
• Orthognathic Surgery - 91273
• Orthoptic and Pleoptic Training for Medicaid Members - 91500
• Orthotics-Shoe Inserts; Orthopedic Shoes Policy - 91420
• Orthotics/Support Devices Policy - 91339  Updated 6/18/08

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P

• PET scans: Policy removed. See AIM guidelines (127KB PDF) for:
  
• Brain imaging
• Cardiac imaging
• Oncology
  
• Panniculectomy/Abdominoplasty - 91444
• Parenteral Nutrition Therapy in the Home - 91517 - Updated 8/20/08
• Pervasive Development Disorders, Including Autistic Spectrum Disorders - 91543
  
• Platelet Rich Plasma/Platelet Rich Fibrin Matrix - 91553 - New 7/18/2008
  

• Port Wine Stains and Vascular Malformations - 91413
• Prolotherapy - 91301
  
• Prophylactic Cancer Risk Reduction Surgery - 91508  Updated 10/20/2008
  Update: Page 2, section 2.A.2(a), language added to coverage criteria
  
• Prosthetics, External - 91306
• Psychological Evaluation and Management of Non-Mental Health Disorders - 91546  Updated 10/20/2008
  Update: CPT/HCPCS codes not covered for PriorityMedicaid and coverage limitations for PriorityMedicare clarified; codes added
  
• Pulse Oximetry for Home Use - 91452  Reviewed 10/20/2008

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Q

• QEEG - Quantitative Electroencephalogram - 91510 Reviewed 8/08

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R

• Radiofrequency Ablation for Back Pain - 91541
  
• Radiosurgery - 91127 Reviewed 8/08
  
• Recurrent Spontaneous Abortion - 91156  Reviewed 10/20/2008
  
• Refractive Keratoplasty/Lasik - 91529 Updated 07/01/08
• Rehabilitative Medicine Services - 91318 Updated and renamed 04/08
  
• Respite Care - 91321
• Robotically Assisted Surgeries - 91522
  

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S

• Septoplasty/Rhinoplasty - 91506
• Sexual Dysfunction and Impotence - 91160
  
• Skin Conditions - 91456   Updated 2/15/2008
  
• Sleep Apnea-Obstructive - 91333
• Speech Therapy - 91336 Updated 2/08
• Sperm and Oocyte Retrieval and Storage - 91393  Reviewed 10/20/2008
  
• Spine Centers of Excellence - 91531 Updated 7/18/2008
  
• Sterilization for Medicaid Members - 91501
• Stereotactic Radiosurgery: See Radiosurgery - 91127
• Stimulation Therapy and Devices - 91468 Updated 08/20/08
• Synagis®/Palivizumab - 91429  Reviewed 10/20/2008
  

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T

• Technology Assessment - 91430
• Temporomandibular Joint Disorders (TMJD) - 91353
• Termination of Pregnancy, Elective - 91000
  
• Thermal Capsulorrhaphy - 91551  New 4/08
  
• Thermography - 91355   Reviewed 10/20/2008
  
• Titanium Rib - 91505
• Tinnitus Retraining Therapy - 91482
• Total Hip Resurfacing - 91530   Updated 2/15/2008
  
• Transcatheter Closure of Septal Defects - 91528 Updated 07/01/08
  
• Transplantation of Solid Organs - 91272

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U

• Umbilical Cord Blood Testing and Storage - 91459
• Uvulopalatopharyngoplasty (UPPP) & Laser-Assisted Uvulopalatoplasty (LAUP): See Obstructive Sleep Apnea - 91333
  

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V

• Vagal Nerve Stimulation as a Treatment of Depression - 91524
• Varicose Vein Treatment - 91326
• Ventricular Assist Devices (VADs) - 91509 Updated 10/20/2008
  Update: Language added for clarification of Medicare coverage criteria
  
• Vertebroplasty/Kyphoplasty - 91479
• Virtual Colonoscopy: Policy retired 4/23/2008; see Colorectal Cancer Screening
  
• Vision Care/Eye Exam - 91538 Updated 04/08
  

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W

X

Y

Z

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