Medical Policy Manual
Table of Contents
Click to go to the first letter of the policy, and then click the Medical Policy Title to view the policy in Adobe Acrobat (.pdf) format.
A | B | C | D | E | F | G | H | I | K | L | M | N | O | P | R | S | T | U | V | W | XYZ
- Alair Bronchial Thermoplasty for the Treatment of Asthma, MPM 1.5
- Ambulance Services, MPM 1.1
- Artificial Disc Replacement, MPM 1.3
- Autism Spectrum Disorders: Diagnosis and Treatment, MPM 1.4
- Autologous Chondrocyte Implantation (Carticel), MPM 3.2
- Bariatric Surgery (Weight Loss Surgery), MPM 2.8
- Blepharoplasty/Ptosis Surgery, MPM 2.7
- Bone Anchored Hearing Aids (BAHA), MPM 2.9
- Brain Natriuretic Peptide Test (BNP) for CHF, MPM 2.10
- Breast Reconstruction Following Mastectomy, MPM 2.11
- Breast Implant Removal and/or Replacement and Capsulectomy, MPM 2.2
- Breast Reduction Mammaplasty for Symptomatic Breast Hypertrophy, MPM 2.5
- Cancer Clinical Trials, Routine Patient Care Costs, MPM 3.7
- Cholecystectomy by Laparoscopy, MPM 3.9
- Chronic Urticaria Testing, In Vitro (CU Index), MPM 3.6
- Clinical Trial Coverage for Members Enrolled in a Medicare Plan, MPM 3.8
- Continuous Glucose Monitoring Systems (See DME: Diabetic Equipment, MPM 4.4)
- Coronary Computed Tomography (64-Slice CT), MPM 3.4
- Cranial Orthotic Devices, (See DME: Orthotics and Prosthetics, MPM 4.6)
- Cryoablation for Prostate Cancer, MPM 3.5
- Diapers (for Salud members only), MPM 4.8
- Durable Medical Equipment: Orthotics and Prosthetics, MPM 4.6
- Durable Medical Equipment: Rehabilitation and Mobility Devices, MPM 4.2
- Durable Medical Equipment: Respiratory Devices, MPM 4.3
- Durable Medical Equipment: Diabetic Equipment, MPM 4.4
- Durable Medical Equipment: Miscellaneous, MPM 4.5
- Durable Medical Equipment for State Coverage Insurance (SCI), MPM 4.7
- Electric Bioimpedance for Assessment of Lymphedema, MPM 5.10
- Electric Bioimpedance for Cardiac Output Monitoring (BioZ), MPM 5.4
- Epidural Corticosteroid Injections for Back Pain, MPM 5.9
- Exhaled Nitric Oxide Testing for the Diagnosis/Management of Asthma, MPM 5.5
- Extracorporeal Photopheresis, MPM 5.7
- Extracorporeal Shock Wave Therapy (ESWT) (OssaTron Lithotripsy), MPM 5.6
- Eye Movement Desensitization and Reprocessing (EMDR), MPM 5.8
- Fecal Microbiota Transplantation (FMT), MPM 6.1
- Foot Splints for Club Foot, MPM 6.0 (See DME: Orthotics and Prosthetics, MPM 4.6)
- Gastric Electric Stimulation for the Treatment of Chronic Gastroparesis, MPM 7.2
- Genetic and Genomic Testing, MPM 7.1
- Gynecomastia, MPM 7.0
- Hip Arthroscopy for Femoroacetabular Impingement (FAI), MPM 8.7
- Hyperbaric Oxygen Therapy, MPM 8.6
- Hysterectomy, MPM 8.9
- Implantable Cardioverter Defibrillators (ICD), MPM 9.5
- InFUSE Bone Graft (recombinant human Bone Morphogenetic Protein), MPM 9.4
- Intervertebral Differential Dynamics Therapy (IDD Therapy), MPM 9.6
- Intracoronary (or Intravascular) Brachytherapy, MPM 9.7
- Intradiscal Electrothermal Therapy (IDET) (See Thermal Intradiscal Procedures, MPM. 20.7)
- Intrafallopian Tube Birth Control Device (ESSURE®), MPM 9.3
- LINX Reflux Management System for the Treatment of GERD, MPM 12.2
- Lumbar Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, MPM 12.0
- Lumbar Fusion, MPM 12.1
- Magnetoencephalography, MPM 13.1
- Medicaid Home Health Services, MPM 13.6
- Meniscal Allograft Transplantation, MPM 13.3
- Minimally Invasive Total Hip Arthroplasty, MPM 13.4
- mild®-Minimally Invasive Lumbar Decompression, MPM 13.5
- Mobile Cardiac Outpatient Telemetry, MPM 13.2
- Panniculectomy and Abdominoplasty, MPM 16.5
- Paravertebral Facet Joint Denervation, MPM 16.6
- Percutaneous Neuromodulation Therapy, MPM 16.8
- Pharmacogenetic Testing for Warfarin Dosing (See Genetic and Genomic Testing, MPM 7.1)
- Photodynamic Therapy for Ocular Conditions, MPM 16.15
- Photodynamic Therapy for Skin and Cancer Conditions, MPM 16.9
- Plasma Exchange for Multiple Sclerosis, Devic's Syndrome, Transverse Myelitis and other conditions, MPM 16.11
- Platelet-Rich Plasma and Platelet-Derived Growth Factor Products (Autologous) for the Treatment of Wounds and Other Injuries, MPM 16.16
- Positron Emission Tomography (PET), MPM 16.1
- Prophylactic Mastectomy and Oophorectomy, with or without Hysterectomy, for Prevention of Cancer, MPM 16.10
- Prostatectomy (Laparoscopic Radical and DaVinci), MPM 16.12
- Proton Beam Therapy, MPM 16.14 (See Radiation Oncology: Proton Beam Therapy)
- Radiation Oncology: Brachytherapy, MPM 18.7
- Radiation Oncology: Stereotactic Radiosurgery, MPM 18.9
- Radiation Oncology: Proton Beam Therapy, MPM 16.14
- Rehabilitation Services for Individuals with Special Healthcare Needs: Physical, Occupational and Speech Therapy, MPM 16.4
- Restorative/Reconstructive/Cosmetic Surgery and Treatment, MPM 18.5
- Salivary Estriol Test and Fetal Fibronectin for Preterm Labor, MPM 19.9
- Secca Procedure for Fecal Incontinence, MPM 19.8
- Subtalar Arthroereisis Implants for Pediatric Patients, MPM 19.6
- Thermal Intradiscal Procedures, MPM 20.7
- Thin-Layer or Liquid-based Cytology Screening, MPM 20.8
- TIF (Transoral Incisionless Fundoplication for Treatment of GERD), MPM 20.12
- Tonsillectomy, MPM 20.0
- Total Ankle Replacement, MPM 20.10
- Total Hip Resurfacing, MPM 20.9
- Transcatheter Aortic Valve Replacement, MPM 20.13
- Transcranial Magnetic Stimulation for Treatment Resistant Depression, MPM 20.11
- Transplants, Bone Marrow and Peripheral Stem Cell, MPM 20.3
- Transplants, Organ, MPM 20.6
- Transpupillary Thermotherapy (TTT), MPM 20.5
- Uterine Artery Embolization for Uterine Fibroids, MPM 21.2
- Uvulopalatopharyngoplasty (UPPP), MPM 21.1
- Vagus Nerve Stimulation, MPM 22.4
- Value Added Services for Salud, MPM 22.3
- Varicose Vein Procedures, MPM 22.1
- Virtual Colonoscopy, MPM 22.0
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