Note: The numbering system in the CareFirst Medical Policy Reference Manual for Medical Policies and Operating Procedures has been slightly modified. Effective 3/2/07, all former two-digit numbers in the third set of numbers (i.e. xx.xx.XX) now have a leading "0" in the third set (i.e. xx.xx.0XX). If you need to search for a Medical Policy or Operating Procedure, make sure you now include a "0" in the first space of the third set of numbers.
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 4/22/13:
4/22/13: Photodynamic Therapy, 2.03.007
Assisted Reproductive Technology (ART): Artificial Insemination (AI) /
Intrauterine Insemination (IUI), 4.02.006A
Magnetic Resonance Neurography, 6.01.039
Bone Lengthening for Angular Deformities and Limb Length Discrepancies of
Long Bones, 7.01.011
Sinus Antrostomy Using Dilation Balloon, 7.01.044
Total Ankle Arthroplasty / Replacement, 7.01.093
Cryosurgical Ablation of Renal Cell Carcinoma, 7.01.098
Peripheral Field Neurostimulation for Chronic Pain, 7.01.120
Genetic Testing for Inherited BRCA1 or BRCA2 Mutations, 11.01.002
In Vitro Chemotherapeutic Drug Assays, 11.01.019
Assays of Genetic Expression in Tumor Tissue to Determine Prognosis in
Breast Cancer Patients, 11.01.032
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 3/25/13:
3/25/13: Dynamic Splinting Systems, 1.01.030
Allergy Immunotherapy, 2.01.017
Carbogen Therapy for Idiopathic Sudden Hearing Loss, 2.01.029
Botulinum Toxin, 5.01.005
Computerized Ophthalmic Diagnostic Imaging, 6.01.031
Intensity Modulated Radiation Therapy, 6.01.038
Therapeutic Apheresis, 7.01.030
Obesity and Morbid Obesity, 7.01.036
Physical Therapy, 8.01.001
Occupational Therapy, 8.01.004
Cathepsin-D, 11.01.005
Cytochrome P450 Genotyping, 11.01.033
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 2/19/13:
2/19/13: Video Electroencephalographic (EEG) Monitoring, 2.01.044
Total Body Photography for Melanoma Risk Monitoring, 2.01.054A
Repository Corticotropin (ACTH) Injections, 2.01.063
Non-Contact Low-Energy Ultrasound Wound Care Therapy, 2.01.069
Lung Volume Reduction Surgery for Palliation of Sever Emphysema, 7.01.062
Interpositional Spacer for Osteoarthritis of the Knee Joint, 7.01.078
Laryngeal Denervation and Reinnervation for Laryngeal Dystonia, 7.01.079
Collagen Meniscus Implant, 7.01.112
Islet Cell Transplantation, 7.03.007
Circulating Tumor Cell Detection in Management of Cancer Patients,
11.01.052
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 1/22/13:
1/22/13: H-Wave Electrical Stimulation Devices for Home Use, 1.01.005
Breast Pumps and Related Supplies, 1.01.070A
Prosthetics, 1.04.001
Hyperbaric Oxygen Therapy, 2.01.004
Diagnostic Eye Procedures with Companion Table, 2.01.038A
Prosthetic Replacement of Ocular Surface Ecosystem (PROSE), 2.01.068
Palivizumab (Synagis) for Immune Prophylaxis for Respiratory Syncytial
Virus, 5.01.019
Fetal Mesencephalic Transplantation for the Treatment of Parkinson's
Disease, 7.01.010
Oral-Facial Pathology or Trauma, 7.01.022
Transpupillary Thermotherapy, 7.01.080
Surgical Treatment of Varicosities, 7.01.082
Gastric Electrical Stimulation, 7.01.097
Topographic Genotyping, Quantitative Mutational Analysis (PathfinderTG),
11.01.040
Noninvasive Prenatal Testing for Fetal Aneuploidy, 11.01.049
HIV Tropism Assay, 11.01.051
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 12/17/12:
12/17/12: Phototherapy, 2.01.007
Electrocorticography, 2.01.011
Xenon Chloride Excimer Laser Therapy for Treatment of Psoriasis and Vitiligo, 2.01.049
Professional Nutritional Counseling, 2.01.050A
Pulsed Radiofrequency Therapy for Chronic Pain, 2.01.067
Antineoplaston A Therapy, 2.03.009
Colony Stimulating Factors, 5.01.003
Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty, 7.01.032
Prolotherapy (Proliferative Therapy), 7.01.067
Spinal Manipulation Under Anesthesia, 7.01.084
Recreational Activity as Physical Therapy, 8.01.009
Monochromatic Infrared Energy (MIRE) Therapy, 8.01.015
Genetic Testing for Predicting Progression of Adolescent Idiopahtic Scoliosis, 11.01.046
Gene Expression Assay for Risk Assessment in Colon Cancer, 11.01.048
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 11/19/12:
11/19/12: Pulsed Electrical Stimulation Device for Osteoarthritis of the Knee, 1.01.017
Neuromuscular Electrical Stimulation (NMES) Devices, 1.01.018
Over-the-Counter Miscellaneous Supplies and Equipment, 1.02.024A
Dynamic Posturography, 2.01.002
Wearable External Cardioverter-Defibrillator, 2.02.011
Treatments for Urinary Incontinence, 7.01.041
Automatic Implantable Cardioverter Defibrillator (AICD), 7.01.087
Endoscopic Therapies for Gastroesophageal Reflux (GERD), 7.01.095
High Dose Chemotherapy / Radiation Therapy with Allogeneic Stem Cell
Support, 7.03.003
Serum Proteomic Pattern Analysis Testing for Screening or Diagnosis of
Ovarian Cancer, 11.01.028
Serum Antibody Marker Testing for Inflammatory Bowel Disease, 11.01.029
Genetic Expression Profiling for Coronary Artery Disease, 11.01.044
Proteomics-Based Testing for Evaluation of Ovarian Masses, 11.01.045
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 10/22/12:
10/22/12: Sensory Stimulation for Coma Patients, 2.01.024
Electromagnetic and Electrical Stimulation for the Care of Chronic Wounds,
2.01.060
Hyperthermia in the Treatment of Cancer, 2.03.004
Electron Beam Computed Tomography to Detect Coronary Artery Calcification,
6.01.003
Dual X-Ral Absorptiometry (DEXA scan) for Determining Body Composition,
6.01.042
Vascular Angioscopy, 7.01.008
Thermal Capsulorrhaphy for Joint Instability, 7.01.029
Electrophrenic Pacemaker, 7.01.037
Functional Neuromuscular Stimulation, 7.01.047
Vagus Nerve Stimulation, 7.01.075
Medical Record Documentation Standards, 10.01.013A
Salivary Estriol for Assessment of Risk for Preterm Labor, 11.01.020
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 9/17/12:
9/17/12: Transcutaneous Electrical Nerve Stimulators (TENS), 1.01.010
Treatments of Tinnitus, 2.01.019
Hair Analysis, 2.01.043
Palivizumab (Synagis) for Immune Prophylaxis for Respiratory Syncytial
Virus (RSV), 5.01.019
Ultrasound for the Evaluation of Paranasal Sinuses, 6.01.014
Neutron Beam Radiotherapy, 6.01.018
Bone-Anchored Hearing Aids, 7.01.003
Dynamic Cardiomyoplasty, 7.01.006
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other
Musculoskeletal Conditions, 7.01.074
Carotid Artery Angioplasty and Stenting, 7.01.086
Mechanical Embolus Retrieval for Acute Ischemic Stroke, 7.01.094
Dynamic Spinal Stabilization, 7.01.096
Bronchial Thermoplasty for Control of Asthma, 7.01.102
Telemedicine (Unified Communications), 10.01.012A
Genetic Testing for Cardiac Ion Channel Mutations, 11.01.039
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 8/20/12:
8/20/12: Contraceptive Supplies, 1.02.022A
Idiopathic Environmental Intolerances, 2.01.001
Surface Electromyography, 2.03.031
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluids, 2.01.045
Autism Spectrum Disorders (Virginia Mandate), 3.01.011A
Recurrent Pregnancy Loss (Recurrent Spontaneous Abortion), 4.02.008
Charged-Particle (Proton or Helium Ion) Radiation Therapy, 6.01.019
Minimally Invasive Lumbar Decompression, 7.01.117
Minimally Invasive Interventions for Fecal Incontinence, 7.01.118
Human Organ Transplants, 7.03.001
High Dose Chemotherapy / Radiation Therapy with Autologous Stem Cell
Support, 7.03.002
Nonmyeloablative Allogeneic Hemopoietic Stem Cell Transplantation for
Hematologic Malignancies, 7.03.006
Anesthesia Services, 9.01.001A
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 7/23/12:
7/23/12: Durable Medical Equipment with Attached Table, 1.01.001
Breast Pumps and Related Supplies, 1.01.070A
Automated Oscillometer Blood Pressure Monitors for Home Use, 1.01.071
Chelation Therapy, 2.01.027
Thoracic Electrical Bioimpedance Measurement, 2.02.003
Spinal Cord and Deep Brain Stimulation, 7.01.025
Pharmacogenomic Testing for Warfarin Sensitivity, 11.01.038
MicroRNA Analysis for Cancer of Unknown Primary Origin, 11.01.042
Systems Pathology for Prediction of Recurrence of Prostate Cancer, 11.01.043
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 6/29/12:
6/29/12: Habilitative Services (MD and DC Mandates), 8.01.011A
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 6/18/12:
6/18/12: Ultrasound Accelerated Fracture Healing Device, 1.01.006
Biofeedback, 2.01.035
Electrical Bone Growth Stimulation, 7.01.007
Functional Neuromuscular Stimulation, 7.01.047
Radiofrequency Ablation of Malignant Tumors of the Lung, 7.01.104
Transanal Endoscopic Microsurgery (TEM), 7.01.111
Cardiac Rehabilitation, 8.01.002
Genetic Testing for Familial Cardiomyopathies, 11.01.050
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 5/21/12:
5/21/12: Photography, 2.01.007
Ultrafiltration for Fluid Overload in Decompensated Heart Failure, 2.02.010
Attention Deficit Disorder (ADD) with or withut Hyperactivity, 3.01.009
Assisted Reproductive Technology (ART) Procedures: In Vitro Fertilization,
(IVF), Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer
(ZIFT), 4.02.001
Radiofrequency Ablation of Malignant Tumors of the Liver, 7.01.073
Minimally Invasive Intervertebral Disc Decompression Procedures for Low
Back Pain, 7.01.091
Interspinous Vertebral Decompression Implantation for Spinal Stenosis,
7.01.092
Endoscopic Radiofrequency Ablation for Barrett's Esophagus, 7.01.105
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 4/23/12:
4/23/12: Digital Pulse Wave Analysis Assessment of Arterial Elasticity, 2.01.066
Microvolt T-Wave Alternans, 2.02.002
Transcatheter Closure of the Left Artial Appendage, 2.02.013
Thermography and Temperature Gradient Studies, 6.01.012
Magnetoencephalography and Magnetic Source Imaging, 6.01.036
Digital Breast Tomosynthesis, 6.01.044
Cavernous Nerve Stimulation Device, 7.01.040
Emergency Services: Auto Codes, 10.01.011A
MaternitT21™ First Trimester Genetic Screening for Trisomy 21, 11.01.049
Archived Temperature Gradient Studies, 2.01.042
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 3/19/12:
3/19/12: Transcranial Magnetic Stimulation for Treatment of Depression and Other
Psychiatric / Neurologic Disorders, 3.01.010
Botulinum Toxin, 5.01.005
Human Growth Hormone (HGH) Therapy for Children and Adults, 5.01.009
Cochlear Implantation, 7.01.005
Cosmetic and Reconstructive Surgery with Attached Companion Table, 7.01.017
Filtration Surgeries for Open Angle Glaucoma, 7.01.110
Transcatheter Aortic Valve Implantation (TAVI), 7.01.114
Transcatheter Pulmonary Valve Implantation, 7.01.116
Dry Needling, 8.01.018
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 2/21/12:
2/21/12: Blood-Derived Growth Factors for Wound Healing, 2.01.016
Quantitative Sensory Testing for Peripheral Neuropathies, 2.01.059
External / Extracorporeal Counterpulsation (ECP/EECP), 2.02.001
Transcatheter Arterial Chemoembolization for Malignant Tumors of the Liver,
2.03.003
Computer Assisted Navigational Techniques in Orthopedic Surgery, 7.01.050A
Vertebral Disc Replacement / Lumber Disc Prosthesis, 7.01.088
Serum Biomarker Panels for Assessment of Hepatic Fibrosis, 11.01.037
KRAS Mutation Analysis in Metastatic Colorectal Cancer, 11.01.041
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 1/23/12:
1/23/12: Durable Medical Equipment with Attached Table, 1.01.001
Home Apnea Monitoring, 1.01.007
Transcutaneous Electrical Nerve Stimulators (TENS), 1.01.010
Wheelchairs and Manual or Power Operated Vehicles, 1.01.014A
Adjustable Cranial Orthoses for Positional Plagiocephaly and for Craniosystosis,
1.03.002
Gait Analysis, 2.01.003
Total Body Photography for Melanoma Risk Monitoring, 2.01.054A
Human Growth Hormone (HGH) Therapy for Children and Adults, 5.01.009
Physical Therapy, 8.01.001
Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary
Carcinoma of the Thyroid, 11.01.007
Hypo-osmotic Swelling Test for Sperm Function, 11.01.009
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 12/19/11:
12/19/11: Erectile Dysfunction, 2.01.025
Neuropsychological Testing, 2.01.028
Monitoring of Regional Cerebral Blood Flow Using Implanted Thermal Infusion,
Probe, 2.01.058
Ingestible pH and Pressure Capsule for Assessing Gastrointestinal Motility,
2.01.065
Adoptive Immunotherapy, 2.03.005
Isolated Limb Perfusion, 2.03.006
Preimplantation Genetic Testing, 4.02.007
Ultrasound (Echography) of the Spinal Canal and Contents, 6.01.024
Cervical Vertebral Disc Replacement, 7.01.100
Speech Therapy, 8.01.005
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 11/21/11:
11/21/11: Durable Medical Equipment with Attached Table, 1.01.001
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory
Disorders, 1.01.012
Tilt Table Test, 2.01.009
Implantable Hormone Replacement Pellets, 2.01.053
Electrocardiographic Body Surface Mapping, 2.02.009
Intellectual Disability, 3.01.004
Autism Spectrum Disorders (Virginia Mandate), 3.01.011A
Carotid Intima-Media Thickness Measurement to Assess Risk for Coronary Artery
Disease, 6.01.041
Emergency Services: Auto Codes, 10.01.011A
Preconception Sex Selection Techniques, 11.01.015
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 10/24/11:
10/24/11: Progesterone Administration for the Prevention of Preterm Labor, 4.01.009
Naltrexone, Extended-Release Injectable Suspension, 5.01.015
Intraoperative Radiation Therapy, 6.01.017
Brachytherapy for Malignant Tumors, 6.01.020
Whole Body Computed Tomography Scan as a Screening Test, 6.01.026
Computed Tomography as a Screening Test for Lung Cancer, 6.01.027
Ultrasound Guided Cryoablation of Benign Fibroadenomas of the Breast, 7.01.085
Percutaneous Intervertebral Thermal Annulophasty Procedures for Low Back
Pain, 7.01.101
Transcatheter Aortic Valve Implantation (TAVI), 7.01.114
Shoulder Resurfacing Arthroplasty, 7.01.115
Salivary Melatonin Profile, 11.01.008
Lipoprotein-Associated Phospholipase A2 (Lp-PLA2)
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 9/19/11:
9/19/11: Extracorporeal Photopheresis, 2.01.051
Measurement of Exhaled Volatile Organic Compounds for Detection of Heart
Transplant Rejection, 2.02.012
Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging), 6.01.005
Magnetic Resonance Imaging (MRI) of the Breast, 6.01.022
Positron Emission Tomography (PET), 6.01.032
Magnetic Resonance Spectroscopy, 6.01.034
Surgical Treatment of Femoroacetabular Impingement, 7.01.109
Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic
Hematopoietic Stem-Cell Transplant, 7.03.005
Emergency Services: Auto Codes, 10.01.011A
Molecular Genetic Expression Test for Identification of Heart Transplant Rejection,
11.01.034
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 8/22/11:
8/22/11: Quantitative Electroencephalogram / Topographic Brain Mapping, 2.01.010
Exhaled Nitric Oxide Measurement for Treatment of Asthma, 2.01.057
Ocular Photoscreening by Primary Physicians to Detect Amblyogenic Disorders,
2.01.061
Microvolt T-Wave Alternans, 2.02.002
Correlated Audioelectric Cardiography, 2.02.008
Tesamorelin (Egrifta) Injection for Lipodystrophy, 5.01.018
Cardiac Computed Tomography (CT) and Coronary CT Angiography (CTA),
6.01.035
Electrical Impedance Scanning of the Breast, 6.01.040
Percutaneous Intracranial Angioplasty With or Without Stent Insertion, 7.01.042
Automatic Implantable Cardioverter Defibrillator (AICD), 7.01.087
Platelet Rich Plasma Injection for Musculoskeletal and Orthopedic Surgical
Applications, 7.01.108
Saturation Biopsy of the Prostate, 7.01.113
Peripheral Arterial Disease Rehabilitation, 8.01.012
Low Level Laser Therapy for Musculoskeletal and Neuromuscular Conditions,
8.01.017
Pharmacogenomic and Serologic Metabolite Markers for Inflammatory Bowel
Disease Patients Treated With Azathioprine, 11.01.031
PCA3 Genetic Assay for Prostate Cancer, 11.01.047
Gene Expression Assay for Risk Assessment in Colon Cancer, 11.01.048
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 7/18/11:
7/18/11: Enteral Nutrition Therapy, 1.02.003
Ambulatory Blood Pressure Monitoring, 2.02.006
Sipuleucel-T Immunotherapy for Metastatic Prostate Cancer, 2.03.013
Focused Ultrasound Ablation of Uterine Fibroids, 6.01.033
Meniscal Allograft Transplantation, 7.01.015
Osteochondral Autografts and Allografts in the Treatment of Focal Articular
Cartilage Lesions, 7.01.045
Autologous Chondrocyte Implantation, 7.01.048
Wireless Capsule Endoscopy (Enteral Camera), 7.01.076
Pulmonary Vein Ablation / Isolation for Atrial Fibrillation, 7.01.090
Ventricular Assist Devices and Associated Services, 7.03.011
Telemedicine (Unified Communications), 10.01.012A
Medical Record Documentation Standards, 10.01.013A
Lipoprotein-Associated Phospholipase A2 (Lp-PLA2), 11.01.036
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 6/20/11:
6/20/11: Crutches and Accessories, 1.01.024A
Sleep Disorders, 2.01.018
Wireless Aneurysm Sac Pressure Monitoring, 2.01.056
Bioimpedance for Assessment of Lymphedema, 2.01.062
Mobile Outpatient Cardiovascular Telemetry, 2.02.007
Progesterone Administration for the Prevention of Preterm Labor, 4.01.009
Zoster Vaccine Live (Oka / Merck) ( Zostavax®), 5.01.016
Transcranial Doppler Ultrasound, 6.01.007
Cosmetic and Reconstructive Surgery with Attached Companion Table, 7.01.017
Percutaneous Electrical Nerve Stimulation, 7.01.023
Placental and Umbilical Cord Blood as a Source of Stem Cells, 7.03.004
Spinal Manipulation and Related Services, 8.01.003
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 5/23/11:
5/23/11: Continuous Passive Motion (CPM) Device, 1.01.011
Intravenous or Subcutaneous Histamine Therapy, 2.01.005
Vision Therapy (Orthoptics / Pleoptics), 2.01.015
Allergy Immunotherapy, 2.01.017
Uterine Artery Embolization for Fibroid Tumors (Leiomyomata), 4.01.008
Botulinum Toxin, 5.01.005
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy with 3-D Conformal
Radiation Therapy, 6.01.010
Scintimammography, 6.01.025
Positron Emission Tomography (PET), 6.01.032
Radioembolization for Primary and Secondary Malignant Hepatic Tumors, 6.01.037
Extracorporeal Shock Wave Lithotripsy for Gallstones, 7.01.035
Photocoagulation of Macular Drusen, 7.01.081
Percutaneous Lysis of Epidural Adhesions, 7.01.083
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 4/18/11:
4/18/11: Emergency Services: Auto Codes, 10.01.011A
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 4/18/11:
4/18/11: Transcutaneous Electrical Nerve Stimulators (TENS), 1.01.010
Transcutaneous Electroneural Stimulation for Relief of Nausea and Vomiting,
1.01.061
Corneal Cross Linking for Treatment of Keratoconus and Corneal Ectasia, 2.01.064
Genetic Testing for Inherited Susceptibility to Colon Cancer, 2.03.010
Screening for Colorectal Cancer, 2.03.011A
Adjunctive Diagnostic Aids for Oral Cancer Screening, 2.03.012
Keratoprosthesis, 7.01.013
Total Hip Resurfacing, 7.01.033
Prophylactic Mastectomy, 7.01.071
Cryosurgical Ablation of Renal Cell Carcinoma, 7.01.098
Cryotherapy Dilation for Peripheral Arterial Disease, 7.01.099
Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease,
11.01.004
Genetic Testing for Celiac Disease, 11.01.035
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 3/21/11:
3/21/11: Rhinomanometry and Acoustic Rhinometry, 2.01.008
Temporomandibular Joint (TMJ) Dysfunction, 2.01.021
Allergy Testing, 2.01.023
Assisted Reproduction Technology (ART): Artificial Insemination (AI) / Intrauterine
Insemination (IUI), 4.02.006A
Magnetic Resonance Neurography, 6.01.039
Sinus Antrostomy Using Dilation Balloon, 7.01.044
Total Ankle Arthroplasty / Replacement, 7.01.093
Tumor Markers, 11.01.001
In Vitro Chemotherapeutic Drug Assays, 11.01.019
Assays of Genetic Expression in Tumor Tissue to Determine Prognosis in Breast
Cancer Patients, 11.01.032
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 2/22/11:
2/22/11: Dynamic Splinting Systems, 1.01.030
Carbogen Therapy for Idiopathic Sudden Hearing Loss, 2.01.029
Photodynamic Therapy, 2.03.007
Computerized Ophthalmic Diagnostic Imaging, 6.01.031
Therapeutic Apheresis, 7.01.030
Obesity and Morbid Obesity, 7.01.036
Treatments for Urinary Incontinence, 7.01.041
Physical Therapy, 8.01.001
Occupational Therapy, 8.01.004
Ambulance Services, 10.01.005
Cathepsin-D, 11.01.005
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 1/18/11:
1/18/11: Allergy Immunotherapy, 2.01.017
Allergy Testing, 2.01.023
Video Electroencephalographic (EEG) Monitoring, 2.01.044
Human Growth Hormone (HGH) Therapy for Children and Adults, 5.01.009
Intensity Modulated Radiation Therapy (IMRT), 6.01.038
Stereotactic Radiosurgey Using Gamma Rays, 6.01.043
Bone Lengthening for Angular Deformities and Limb Length Discrepancies of Long
Bones, 7.01.011
Cosmetic and Reconstructive Surgery with Attached Companion Table, 7.01.017
Interpositional Spacer for Osteoarthritis of the Knee Joint, 7.01.078
Laryngeal Denervation and Reinnervation for Laryngeal Dystonia, 7.01.079
Human Organ Transplants, 7.03.001
Islet Cell Transplantation, 7.03.007
Speculoscopy for Cervical Cancer Screening, 11.01.030A
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 12/20/10:
12/20/10: H-Wave Electrical Stimulation Devices for Home Use, 1.01.005
Coverage for Hearing Aids (Maryland Mandate), 1.01.016A
Walkers and Accessories, 1.01.057A
Image-Guided Surgery, 6.01.021A
Fetal Mesencephalic Transplantation for the Treatment of Parkinson's Disease,
7.01.010
Functional Neuromuscular Stimulation, 7.01.047
Lung Volume Reduction Surgery for Palliation of Severe Emphysema, 7.01.062
Transpupillary Thermotherapy, 7.01.080
Spinal Manipulation Under Anesthesia, 7.01.084
Gastric Electrical Stimulation, 7.01.097
Collagen Meniscus Implant, 7.01.112
Vertebral Axial Decompression, 8.01.013A
Monochromatic Infrared Energy (MIRE) Therapy, 8.01.015
Anesthesia Consultation, 9.01.004A
Private Room, 10.01.007A
Telemedicine (Virginia Mandate only), 10.01.012A
Genetic Testing for Inherited BRCA1 or BRCA2 Mutations, 11.01.002
Cytochrome P450 Genotyping, 11.01.033
Topographic Genotyping, Quantitative Mutational Analysis (PathfinderTG®), 11.01.040
KRAS Mutation Analysis in Metastatic Colorectal Cancer, 11.01.041
Genetic Testing for Predicting Progression of Adolescent Idiopathic Scoliosis,
11.01.046
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 11/22/10:
11/22/10: Canes and Accessories, 1.01.072A
Mechanical Lifts, 1.01.073A
Casting and Splinting Supplies, 1.02.009A
Prosthetics, 1.04.001
Electrocorticography, 2.01.011
Professional Nutritional Counseling, 2.01.050A
Antineoplaston A Therapy, 2.03.009
Obesity and Morbid Obesity, 7.01.036
Prolotherapy (Proliferative Therapy), 7.01.067
Surgical Treatment of Varicosities, 7.01.082
Recreational Activity as Physical Therapy, 8.01.009
General Anesthesia for Dental Care (Maryland and Virginia Mandates), 9.01.007A
Attendance at Delivery, 10.01.002A
Surgical Assistants, 10.01.008A
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 10/18/10:
10/18/10: Enuresis Alarm, 1.01.075A
Amino Acid-Based Elemental Formulas for Treatment of Malabsorption Disorders,
1.02.002
Enteral Nutrition Therapy, 1.02.003
Dynamic Posturography, 2.01.002
Hyperbaric Oxygen Therapy, 2.01.004
Allergy Testing, 2.01.023
Medical Foods for Treatment of Inherited Metabolic Disorders, 2.01.026
Diagnostic Eye Procedures with Companion Table, 2.01.038A
Repository Corticotropin (ACTH) Injection, 2.01.063
Off-Label and Orphan Drug Use, 5.01.001
Colony Stimulating Factors, 5.01.003
Thermal Capsulorrhaphy for Joint Instability, 7.01.029
Endoscopic Therapies for Gastroesophageal Reflux, 7.01.095
Serum Proteomic Pattern Analysis Testing for Screening or Diagnosis of Ovarian
Cancer, 11.01.028
Serum Antibody Marker Testing for Inflammatory Bowel Disease, 11.01.029
Genetic Expression Profiling for Coronary Artery Disease, 11.01.044
Proteomics-Based Testing for Evaluation of Ovarian Masses, 11.01.045
NEW/POLICY/OPERATING PROCEDURE REVISION: Update 10/01/10:
10/01/10: Pulsed Electrical Stimulation Device for Osteoarthritis of the Knee, 1.01.017
Neuromuscular Electrical Stimulation (NMES) Devices, 1.01.018
Seat Lift Mechanisms, 1.01.051A
Driving Aids, 1.01.074A
Sensory Stimulation for Coma Patients, 2.01.024
Xenon Chloride Excimer Laser Therapy for Treatment of Psoriasis, 2.01.049
Electromagnetic and Electrical Stimulation for the Care of Chronic Wounds, 2.01.060
Dual X-Ray Absorptiometry (DEXA scan) for Determining Body Composition, 6.01.042
Vascular Angioscopy, 7.01.008
Robotic-Assisted Surgery, 7.01.106A
Emergency Services: Auto Codes, 10.01.011A
Preventable Adverse Events, 10.01.014A
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 9/20/10:
9/20/10: Phototherapy, 2.01.007
Hyperthermia in the Treatment of Cancer, 2.03.004
Electron Beam Computed Tomography to Detect Coronary Artery Calcification,
6.01.003
Oral-Facial Pathology or Trauma, 7.01.022
Electrophrenic Pacemaker, 7.01.037
Vagus Nerve Stimulation, 7.01.075
Neurosurgical Interventions for Cervicogenic Headache / Occipital Neuralgia, 7.01.107
Salivary Estriol for Assessment of Risk for Preterm Labor, 11.01.020
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 8/30/10:
8/30/10: Urinal / Bedpan, 1.01.054A
Protective Wear, 1.02.017A
Treatments of Tinnitus, 2.01.019
Temperature Gradient Studies, 2.01.042
Sipuleucel-T Immunotherapy for Metastatic Prostate Cancer, 2.03.013
Ultrasound for the Evaluation of Paranasal Sinuses, 6.01.014
Dynamic Cardiomyoplasty, 7.01.006
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal
Conditions, 7.01.074
Carotid Artery Angioplasty and Stenting, 7.01.086
Bronchial Thermoplasty for Control of Asthma, 7.01.102
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 8/23/10:
8/23/10: Air Fluidized Beds, 1.01.002
Over-the-Counter Miscellaneous Supplies and Equipment, 1.02.024A
Hair Analysis, 2.01.043
Intravenous Immune Globulin (IVIG) Therapy, 5.01.013
Neutron Beam Radiotherapy, 6.01.018
Charged-Particle (Proton or Helium Ion) Radiation Therapy, 6.01.019
Bone-Anchored Hearing Aids, 7.01.003
Cosmetic and Reconstructive Surgery with Attached Companion Table, 7.01.017
Genetic Testing for Cardiac Ion Channel Mutations, 11.01.039
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 7/26/10:
7/26/10: Incontinent Garments, 1.02.020A
Exercise Equipment, 1.02.021A
Contraceptive Supplies, 1.02.022A
Antiseptic Solutions, 1.02.023A
Idiopathic Environmental INtolerances, 2.01.001
Surface Electromyography, 2.01.031
Mechanical Embolus Retrieval for Acute Ischemic Stroke, 7.01.094
Dynamic Spinal Stabilization, 7.01.096
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 7/19/10:
7/19/10: Fracture/Traction Frames and Associated Equipment, 1.01.031
Sphygmomanometer and Stethoscope, 1.01.047A
Sitz, 1.01.052A
Helmets, 1.02.019A
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid, 2.01.045
Wearable External Cardioverter-Defibrillator, 2.02.011
Global Maternity Care, 4.01.006A
Recurrent Pregnancy Loss, (Recurrent Spontaneous Abortion), 4.02.008
Naltrexone, Extended-Release Injectable Suspension, 5.01.015
Obesity and Morbid Obesity, 7.01.036
Treatments for Urinary Incontinence, 7.01.041
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 6/21/10:
6/21/10: Ultrasound Accelerated Fracture Healing Device, 1.01.006
Bathroom Aids, 1.01.021A
Bed Related Accessories, 1.01.022A
Cold Pad / Cold Pressure Therapy, 1.01.027A
Commode Chair, 1.01.028A
Heating Pat, 1.01.032A
Restraints, 1.01.049A
Vaporizer, 1.01.055A
Automated Oscillometer Blood Pressure Monitors for Home Use, 1.01.071
Sleep Disorders, 2.01.018
Chelation Therapy, 2.01.027
Acupuncture, 2.01.048A
Bioimpedance for Assessment of Lymphedema, 2.01.062
Thoracic Electrical Bioimpedance Measurement, 2.02.003
Spinal Cord and Deep Brain Stimulation, 7.01.025
Clinical Trial Mandates, Maryland and Virginia, 10.01.001A
Pharmacogeomic Testing for Warfarin Sensitivity, 11.01.038
MicroRNA Analysis for Cancer of Unknown Primary Origin, 11.01.042
Systems Pathology for Prediction of Recurrence of Prostate Cancer, 11.01.043
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 5/24/10:
5/24/10: Therapeutic Shoes for Individuals with Diabetes, 1.02.015
Electrical Bone Growth Stimulation, 7.01.007
Percutaneous Vertebroplasty and Kyphoplasty, 7.01.032
Functional Neuromuscular Stimulation, 7.01.047
Transanal Endoscopic Microsurgery (TEM), 7.01.111
High Dose Chemotherapy / Radiation Therapy with Autologous Stem Cell Support,
7.03.002
High Dose Chemotherapy / Radiation Therapy with Allogeneic Stem Cell Support,
7.03.003
Placental and Umbilibcal Cord Blood as a Source of Stem Cells, 7.03.004
Cardiac Rehabilitarion, 8.01.002
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 5/17/10:
5/17/10: Ultrafiltration for Fluid Overload in Decompensated Heart Failure, 2.02.010
Selective Internal Radiation Therapy for Malignant Hepatic Tumors, 6.01.037
Minimally Invasive Intervertebral Disc Decompression Procedures for Low Back Pain,
7.01.091
Intraspinous Vertebral Decompression Implantation for Spinal Stenosis, 7.01.092
Moderate (Conscious) Sedation, 9.01.003A
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric
Infusion Pump, 9.01.008A
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 4/26/10:
4/26/10: Dehumidifier / Humidifier, 1.01.029A
Orthotic Devices and Orthopedic Appliances, 1.03.001
Orthotic Foot Inserts, 1.03.003
Thermography, 6.01.012
Radiofrequency Ablation of Malignant Tumors of the Liver, 7.01.073
Radiofrequency Ablation of Malignant Tumors of the Lung, 7.01.104
Endoscopic Radiofrequency Ablation for Barrett's Esophagus, 7.01.105
Nonmyeloablative Allogeneic Hemopoietic Stem Cell Transplantation for Hematologic
Malignancies, 7.03.006
Intravenous Patient-Controlled Analgesia (IV PCA), 9.01.002A
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 3/15/10:
3/15/10: Air Cleaner / Purifier, 1.01.019A
Cervical Pillow, 1.01.025A
Dynamic Splinting Systems, 1.01.030
Lumbar Roll Cushion, 1.01.035A
Massage Devices, 1.01.036A
Biofeedback, 2.01.035
Professional Nutritional Counseling, 2.01.050A
Quantitative Sensory Testing for Peripheral Neuropathies, 2.01.059
Attention Deficit Disorder (ADD) with or without Hyperactivity, 3.01.009
Botulinum Toxin, 5.01.005
Cochlear Implantation , 7.01.005
Cavernous Nerve Stimulation Device, 7.01.040
NEW POLICY/OPERATING PROCEDURE REVISIONS: Updated 3/1/10:
3/1/10: Dry Needling, 8.01.018
Preventable Adverse Events, 10.01.014A
NEW POLICIES/OPERATING PROCEDURE REVISIONS: Updated 2/22/10:
2/22/10: Blood-Derived Growth Factors for Wound Healing, 2.01.016
Assisted Reproductive Technology (ART) Procedures: In Vitro Fertilization (IVF),
Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), 4.02.001
Human Papillomavirus (HPV) Recombinant Vaccines (quadrivalent and bivalent),
5.01.017
Magnetoencephalography and Magnetic Source Imaging, 6.01.036
Cosmetic and Reconstructive Surgery with Attached Companion Table, 7.01.017
Computer Assisted Navigational Techniques in Orthopedic Surgery, 7.01.050A
Vertebral Disk Replacement / Lumbar Disk Prosthesis, 7.01.088
Bronchial Thermoplasty for Control of Asthma, 7.01.102
NEW POLICIES/OPERATING PROCEDURE REVISIONS: Updated 1/19/10:
1/19/10: Augmentative Communication Devices, 1.01.015A
Total Body Photography for Melanoma Risk Monitoring, 2.01.054A
External / Extracorporeal Counterpulsation (ECP or EECP), 2.02.001
Transcatherter Arterial Chemoembolization for Malignant Tumors of the Liver, 2.03.003
Cervical Vertebral Disc Replacement, 7.01.100
Genetic Testing for Canavan Disease, 11.01.027
Serum Biomarker Panels for Assessment of Hepatic Fibrosis, 11.01.037
NEW POLICIES/OPERATING PROCEDURE REVISIONS: Updated 12/21/09:
12/21/09: Home Apnea Monitoring, 1.01.007
Cranial Orthotic Molding Devices, 1.03.002
Gait Analysis, 2.01.003
Sleep Disorders, 2.01.018
Transcranial Magnetic Stimulation for Treatment of Depression and Other
Psychiatic/Neurologic DIsorders , 3.01.010
Total Ankle Arthroplasty / Replacement, 7.01.093
Lymphedema Therapy (Complex Decongestive Therapy), 8.01.014
Global Surgical Care Rules, 10.01.009A
Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary
Carcinoma of the Thyroid , 11.01.007
Hypo-osmotic Swelling Test for Sperm Function, 11.01.009
Genetic Testing for Cystic Fibrosis, 11.01.025
Testing for Tay-Sachs Disease, 11.01.026
NEW POLICY : Updated 12/10/09: Policy Effective 3/1/2010
12/10/09: Preventable Adverse Events, 10.01.014 - Effective 3/1/2010
NEW POLICIES/OPERATING PROCEDURE REVISIONS: Updated 11/23/09:
11/23/09: Amino Acid-Based Elemental Formulas for Treatment of Malabsorption Disorders,
1.02.002
Orthotic Devices and Orthopedic Appliances, 1.03.001
Erectile Dysfunction, 2.01.025
Neuropsychological Testing, 2.01.028
Professional Nutritional Counseling, 2.01.050A
Implantable Hormone Replacement Pellets, 2.01.053
Monitoring of Regional Cerebral Blood Flow Using Implanted Cerebral Thermal
Infusion Probe, 2.01.058
Adoptive Immunotherapy, 2.03.005
Isolated Limb Perfusion, 2.03.006
Preimplantation Genetic Testing, 4.02.007
Ultrasound (Echography) of the Spinal Canal and Contents, 6.01.024
Filtration Surgeries for Open Angle Glaucoma, 7.01.110
Speech Therapy, 8.01.005
Preconception Sex Selection Techniques, 11.01.015
NEW POLICIES/OPERATING PROCEDURE REVISIONS: Updated 10/19/09:
10/19/09: Policies and Operating Procedures Revised:
Prosthetics, 1.04.001
Tilt Table Test, 2.01.009
Electrocardiographic Body Surface Mapping, 2.02.009
Intellectual Disability, 3.01.004
Carotid Imtima-Media Thickness Measurement to Assess Risk for Coronary Artery Disease, 6.01.041
Infrared Coagulation for Internal Hemorrhoids, 7.01.089
Percutaneous Intervertebral Thermal Annuloplasty Procedures for Low Back Pain, 7.01.101
Habilitative Services (MD and DC mandates), 8.01.011A
Preventive Services, 10.01.003A
NEW POLICIES/REVISIONS: Updated 9/21/09:
9/21/09: Policies and Operating Procedures Revised:
Hypnosis/Hypnotherapy, 2.01.006A
Refraction, 2.01.040A
Extracorporeal Photopheresis, 2.01.051
Progesterone Administration for the Prevention of Preterm Labor, 4.01.009
Brachytherapy for Malignant Tumors, 6.01.020
Whole Body Computed Tomography Scan as a Screening Test, 6.01.026
Computed Tomography as a Screening Test for Lung Cancer, 6.01.027
Surgical Treatment of Femoroacetabular Impingement, 7.01.109
Emergency Services: Auto Codes, 10.01.011A
NEW POLICIES/REVISIONS: Updated 9/14/09:
9/14/09: Policies and Operating Procedures Revised:
Multifetal Pregnancy Reduction, 4.02.003A
Intraoperative Radiation Therapy, 6.01.017
Ultrasound Guided Cryoablation of Benign Fibroadenomas of the Breast, 7.01.085
Diagnosis: Family History of, 10.01.010A
Salivary Melatonin Profile, 11.01.008
NEW POLICIES/REVISIONS: Updated 8/17/09:
8/17/09: Policies and Operating Procedures Revised:
Transcutaneous Electrical Nerve Stimulators (TENS), 1.01.010
High Frequency Chest Wall Oscillation Vest, 1.01.012
Over-the-Counter Miscellaneous Supplies and Equipment, 1.02.024A
Eyeglasses and Contact Lenses for Medical or Post-Operative Conditions, 2.01.039A
Ocular Photoscreening by Primary Physicians to Detect Amblyogenic Disorders,
2.01.061
Measurement of Exhaled Volatile Organic Coumpounds for Detection of Heart
Transplant Rejection, 2.02.012
Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging), 6.01.005
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy, 6.01.010
Magnetic Resonance Imaging (MRI) of the Breast, 6.01.022
Magnetic Resonance Spectroscopy, 6.01.034
Surgical Correction of Refractive Errors, 7.01.020A
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal
Conditions, 7.01.074
Platelet Rich Plasma Injection for Musculoskeletal and Orthopedic Surgical
Applications, 7.01.108
Donor Leukocyte Infusion, 7.03.005
Molecular Genetic Expression Test for Identification of Heart Transplant Rejection,
11.01.034
NEW POLICIES/REVISIONS: Updated 8/3/09:
8/3/09: Policies and Operating Procedures Revised:
Correlated Audioelectric Cardiography, 2.02.008
Electrical Impedance Scanning of the Breast, 6.01.040
Peripheral Arterial Disease Rehabilitation, 8.01.012
Anesthesia Services, 9.01.001A
Epidural / Intrathecal Analgesia, Post-Operative or Non-Surgical, 9.01.005A
Care of the Normal Newborn, 10.01.006
Pharmacogenomic and Serologic Metabolite Markers for Inflammatory Bowel Disease
Patients Treated with Azathioprine, 11.01.031
NEW POLICIES/REVISIONS: Updated 7/20/09:
7/20/09: Policies and Operating Procedure Revised:
Quantitative Electroencephalogram / Togopraphic Brain Mapping, 2.01.010
Exhaled Nitric Oxide Measurement for Treatment of Asthma, 2.01.057
Microvolt T-Wave Alternans, 2.02.002
Automatic Implantable Cardioverter Defibrillator (AICD), 7.01.087
Habilitative Services (MD and DC Mandates), 8.01.011A
Low Level Laser Therapy for Musculoskeletal and Neuromuscular Conditions,
8.01.017
NEW POLICIES/REVISIONS: Updated 6/22/09:
6/22/09: Policies and Operating Procedure Revised:
Durable Medical Equipment with Attached Table, 1.01.001
Crutches and Accessories, 1.01.024A
Ambulatory Blood Pressure Monitoring, 2.02.006
Focused Ultrasound Ablation of Uterine Fibroids, 6.01.033
Meniscal Allograft Transplantation, 7.01.015
Archived Osteochondral Autograft Transfer System (OATS) Procedure, 7.01.034
Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage
Lesions, 7.01.045
Autologous Chondrocyte Implantation, 7.01.048
Wireless Capsule Endoscopy (Enteral Camera), 7.01.076
Surgical Treatment of Varicosities, 7.01.082
Pulmonary Vein Ablation / Isolation for Atrial Fibrillation, 7.01.090
Ventricular Assist Devices and Associated Services, 7.03.011
Lipoprotein-Associated Phospholipase A2 (Lp-PLA2), 11.01.036
NEW POLICY/REVISION: Updated 6/1/09:
6/1/09: Policy Revised:
Cardiac Computed Tomography (CT) and Coronary CT Angiography (CTA), 6.01.035
NEW POLICIES/REVISIONS: Updated 5/18/09:
5/18/09: Policies and Operating Procedures Revised:
Sleep Disorders, 2.01.018
Wireless Aneurysm Sac Pressure Monitoring, 2.01.056
Mobile Outpatient Cardiovascular Telemetry, 2.02.007
Transcranial Doppler Ultrasound, 6.01.007
Percutaneous Electrical Nerve Stimulation (PENS), 7.01.023
Percutaneous Intracranial Angioplasty With or Without Stent Insertion, 7.01.042
Vagus Nerve Stimulation, 7.01.075
Placental and Umbilical Cord Blood as a Source of Stem Cells, 7.03.004
Spinal Manipulation and Related Services, 8.01.003
Work Hardening Programs, 8.01.007A
Obstetrical Anesthesia Services, 9.01.006A
NEW POLICIES/REVISIONS: Updated 4/21/09:
4/21/09: Policies Revised:
Continuous Passive Motion (CPM) Device, 1.01.011
Scintimammography, 6.01.025
Photocoagulation of Macular Drusen, 7.01.081
Percutaneous Lysis of Epidural Adhesions, 7.01.083
NEW POLICIES/REVISIONS: Updated 4/20/09:
4/20/09: Policies Revised:
Cranial Orthotic Molding Devices, 1.03.002
Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine
(e.g., Gardasil®), 5.01.017
Foot Care Services, 7.01.018
Extracorporeal Shock Wave Lithotripsy for Gallstones, 7.01.035
NEW POLICIES/REVISIONS: Updated 4/13/09:
4/13/09: Policies and Operating Procedures Revised:
Intravenous or Subcutaneous Histamine Therapy, 2.01.005
Cervicography (Cervigram), 4.01.004A
Uterine Artery Embolization for Fibroid Tumors (Leiomyomata), 4.01.008
Mifepristone (e.g. Mifeprex™, RU 486), 5.01.014A
Zoster Vaccine Live (Oka/Merck) (e.g. Zostavax®), 5.01.016
Positron Emission Tomography (PET), 6.01.032
Standby Services, 10.01.004A
Medical Record Documentation Standards, 10.01.013A
Genetic Testing for Inherited BRCA1 or BRCA2 Mutations, 11.01.002
NEW POLICIES/REVISIONS: Updated 3/30/09:
3/30/09: Policies Revised:
Adjunctive Diagnostic Aids for Oral Cancer Screening, 2.03.012
Cryosurgical Ablation of Renal Cell Carcinoma, 7.01.098
Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease,
11.01.004
NEW POLICIES/REVISIONS: Updated 3/13/09:
3/13/09: Policies and Operating Procedures Revised:
Infant Hearing Screening (MD, VA and DC Mandates), 2.01.046A
Screening for Colorectal Cancer, 2.03.011A
Archived Computed Tomographic Colonography as a Test for Colon Cancer (Virtual
Colonoscopy), 6.01.028
Keratoprosthesis, 7.01.013
Total Hip Resurfacing, 7.01.033
Cryotherapy Dilation for Peripheral Arterial Disease, 7.01.099
Genetic Testing for Celiac Disease, 11.01.035
NEW POLICIES/REVISIONS: Updated 2/23/09:
2/23/09: Policies Revised:
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid, 2.01.045
Tumor Markers, 11.01.001
Assays of Genetic Expression in Tumor Tissue to Determine Prognosis in Breast
Cancer Patients, 11.01.032
NEW POLICIES/REVISIONS: Updated 2/18/09:
2/18/09: Operating Procedures Revised:
Walkers and Accessories, 1.01.057A
Canes and Accessories, 1.01.072A
NEW POLICIES/REVISIONS: Updated 2/17/09:
2/17/09: Policies Revised:
Rhinomanometry and Acoustic Rhinometry, 2.01.008
Allergy Testing, 2.01.023
Obesity and Morbid Obesity, 7.01.036
Total Ankle Arthroplasty/Replacement, 7.01.093
In Vitro Chemotherapeutic Drug Assays, 11.01.019
NEW POLICIES/REVISIONS: Updated 1/20/09:
1/20/09: Policies Revised:
Photodynamic Therapy, 2.03.007
Human Growth Hormone (HGH) Therapy for Children and Adults, 5.01.009
Physical Therapy, 8.01.001
NEW POLICIES/REVISIONS: Updated 1/9/09:
1/9/09: Policies and Operating Procedures Revised:
Medical Policy Reference Manual : Medical Policy Reference Manual and Archived
Documents
Coverage for Hair Prostheses, 1.01.013A
Temporomandibular Joint (TMJ) Dysfunction, 2.01.021
Carbogen Therapy for Idiopathic Sudden Hearing Loss, 2.01.029
Low Osmolar Contrast Media, 6.01.013A
Therapeutic Apheresis, 7.01.030
Occupational Therapy, 8.01.004
Cathepsin-D, 11.01.005
NEW POLICIES/REVISIONS: Updated 12/29/08:
12/29/08: Policies Revised:
Electromagnetic and Electrical Stimulation for the Care of Chronic Wounds, 2.01.060
Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine (e.g.,
Gardasil®), 5.01.017
Prophylactic Mastectomy, 7.01.071
Interpositional Spacer for Osteoarthritis of the Knee Joint, 7.01.078
NEW POLICIES/REVISIONS: Updated 12/22/08:
12/22/08: Policies and Operating Procedure Revised:
Bone Lengthening for Angular Deformities and Limb Lengthening Discrepancies of
Long Bones, 7.01.011
Sinus Antrostomy Using Dilation Balloon, 7.01.044
Laryngeal Denervation and Reinnervation for Laryngeal Dystonia, 7.01.079
Human Organ Transplants, 7.03.001
Islet Cell Transplantation, 7.03.007
Speculoscopy for Cervical Cancer Screening, 11.01.030A
NEW POLICIES/REVISIONS: Updated 11/17/08:
11/17/08: Policies and Operating Procedures Revised:
Durable Medical Equipment with Attached Table, 1.01.001
Walkers and Accessories, 1.01.057A
Over-the-Counter Miscellaneous Supplies and Equipment, 1.02.024A
Allergy Immunotherapy, 2.01.017
Cytochrome P450 Genotyping, 11.01.033
Topographic Genotyping, Quantitative Mutational Analysis, e.g. PathfinderTG®,
11.01.040
KRAS Mutation Analysis in Metastatic Colorectal Cancer, 11.01.041
NEW POLICIES/REVISIONS: Updated 11/14/08:
11/14/08: Policies and Operating Procedures Revised:
Coverage for Hearing Aids (Maryland Mandate), 1.01.016A
Video Electroencephalographic (EEG) Monitoring, 2.01.044
Genetic Testing for Inherited Susceptibility to Colon Cancer, 2.03.010
Assisted Reproductive Technology (ART) Procedures: IVF, GIFT, ZIFT, 4.02.001
Assisted Reproductive Technology (ART): AI/ IUI, 4.02.006A
Image-Guided Surgery, 6.01.021A
Magnetic Resonance Neurography, 6.01.039
Fetal Mesencephalic Transplantation for the Treatment of Parkinson's Disease,
7.01.010
Lung Volume Reduction Surgery for Palliation of Severe Emphysema, 7.01.062
Transpupillary Thermotherapy, 7.01.080
Anesthesia Consultation, 9.01.004A
Private Room, 10.01.007A
POLICIES/REVISIONS: Updated 10/24/08:
10/24/08: Policies and Operating Procedures Revised:
H-Wave Electrical Stimulation Devices for Home Use, 1.01.005
Electrocorticography, 2.01.011
Antineoplastin A Therapy, 2.03.009
Computerized Ophthalmic Diagnostic Imaging, 6.01.031
Prolotherapy (Proliferative Therapy), 7.01.067
Spinal Manipulation Under Anesthesia, 7.01.084
Gastric Electical Stimulation, 7.01.097
Recreational Activity as Physical Therapy (e.g., Golf, Hippotherapy), 8.01.009
Vertebral Axial Decompression, 8.01.013A
Monochromatic Infrared Energy (MIRE) Therapy, 8.01.015
General Anesthesia for Dental Care (Maryland and Virginia Mandates), 9.01.007A
Attendance at Delivery, 10.01.002A
Surgical Assistants, 10.01.008A
NEW POLICIES/REVISIONS: Updated 10/20/08:
10/20/08: Policies and Operating Procedures Revised:
Durable Medical Equipment with Attached Table, 1.01.001
Canes and Accessories, 1.01.072A
Orthotic Foot Inserts, 1.03.003
Prosthetics, 1.04.001
Vision Therapy (Orthoptics/Pleoptics, 2.01.015
Professional Nutritional Counseling, 2.01.050A
NEW POLICIES/REVISIONS: Updated 9/22/08:
9/22/08: Policies and Operating Procedures Revised:
Durable Medical Equipment with Attached Table, 1.01.001
Mechanical Lifts, 1.01.073A
Enuresis Alarm, 1.01.075A
Amino Acid-Based Elemental Formulas for Treatment of Malabsorption Disorders,
1.02.002
Enteral Nutrition Therapy, 1.02.003
Casting and Splinting Supplies, 1.02.009A
Off-Label and Orphan Drug Use, 5.01.001
Dual X-Ray Absorptiometry (DEXA scan) for Determining Body Composition, 6.01.042
Emergency Services: Auto Codes, 10.01.011A
Serum Antibody Marker Testing for Inflammatory Bowel Disease, 11.01.029
NEW POLICIES/REVISIONS: Updated 9/17/08:
9/17/08: Policies Revised:
Dynamic Posturography, 2.01.002
Medical Foods for Treatment of Inherited Metabolic Disorders, 2.01.026
Thermal Capsulorrhaphy for Joint Instability, 7.01.029
Computer Assisted Navigational Techniques in Orthopedic Surgery, 7.01.050
Surgical Treatment of Varicosities, 7.01.082
Endoscopic Therapies for Gastroesophageal Reflux, 7.01.095
Serum Proteomic Pattern Analysis Testing for Screening or Diagnosis of Ovarian
Cancer. 11.01.028
NEW POLICIES/REVISIONS: Updated 8/29/08:
8/29/08: Policy Revised:
Assays of Genetic Expression in Tumor Tissue to Determine Prognosis in Breast
Cancer Patients, 11.01.032
NEW POLICIES/REVISIONS: Updated 8/18/08:
8/18/08: Policies and Operating Procedures Revised:
Durable Medical Equipment with Attached Companion Table, 1.01.001
Seat Lift Mechanisms, 1.01.051A
Driving Aids, 1.01.074A
DIagnostic Eye Procedures with Companion Table, 2.01.038A
Electron Beam Computed Tomography to Detect Coronary Artery Calcification,
6.01.003
Vagus Nerve Stimulation, 7.01.075
Robotic-Assisted Surgery, 7.01.106A
Neurosurgical Interventions for Cervicogenic Headache / Occipital Neuralgia, 7.01.107
Ambulance Services, 10.01.005
Salivary Estriol for Assessment of Risk for Preterm Labor, 11.01.020
NEW POLICIES/REVISIONS: Updated 8/11/08:
8/11/08: Policies Revised:
Pulsed Electrical Stimulation Device for Osteoarthritis of the Knee, 1.01.017
Sensory Stimulation for Coma Patients, 2.01.024
Hyperthermia in the Treatment of Cancer, 2.03.004
Vascular Angioscopy, 7.01.008
Oral-Facial Pathology or Trauma, 7.01.022
Electrophrenic Pacemaker, 7.01.037
NEW POLICIES/REVISIONS: Updated 7/21/08:
7/21/08: Policies and Operating Procedures Revised:
Durable Medical Equipment with Attached Companion Table, 1.01.001
Urinal / Bedpans, 1.01.054A
Protective Wear, 1.02.017A
Temperature Gradient Studies, 2.01.042
Electrothermal Coagulation of Barrett's Esophagus, 7.01.105
Ambulance Services, 10.01.005
Genetic Testing for Cardiac Ion Channel Mutations, 11.01.039
NEW POLICIES/REVISIONS: Updated 7/11/08:
7/11/08: Policies Revised:
Air Fluidized Beds, 1.01.002
Treatments of Tinnitus, 2.01.019
Hair Analysis, 2.01.043
Ultrasound for the Evaluation of Paranasal Sinuses, 6.01.014
Neutron Beam Radiotherapy, 6.01.018
Charged Particle (Proton or Helium Ion) Radiation Therapy, 6.01.019
Positron Emission Tomography (PET), 6.01.032
Dynamic Cardiomyoplasty, 7.01.006
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal
Conditions, 7.01.074
NEW POLICIES/REVISIONS: Updated 6/23/08:
6/23/08: Policies and Operating Procedures Revised:
Incontinent Garments, 1.02.020A
Exercise Equipment, 1.02.021A
Contraceptive Supplies, 1.02.022A
Antiseptic Solutions, 1.02.023A
Over-the-Counter Miscellaneous Supplies, 1.02.024A
Surface Electromyography, 2.01.031
Continuous Glucose Monitoring (Diagnostic Test), 2.01.045
Wearable External Cardioverter-Defibrillator, 2.02.011
Naltrexone, Extended-Release Injectable Suspension (e.g. Vivitrol®), 5.01.015
Radiofrequeny Ablation of Malignant Tumors of the Lung, 7.01.104
NEW POLICIES/REVISIONS: Updated 6/16/08:
6/16/08: Policies Revised:
Idiopathic Environmental Intolerances, 2.01.001
Intensity Modulated Radiation Therapy (IMRT), 6.01.038
Obesity and Morbid Obesity, 7.01.036
NEW POLICIES/REVISIONS: Updated 5/19/08:
5/19/08: Policies and Operating Procedures Revised:
Neuromuscular Electrical Stimulation (NMES) Devices, 1.01.018
Helmets, 1.02.019A
Global Maternity Care, 4.01.006A
Recurrent Pregnancy Loss (Recurrent Spontaneous Abortion), 4.02.008
Cosmetic and Reconstructive Surgery with Attached Companion Table, 7.01.017
Carotid Artery Angioplasty and Stenting, 7.01.086
Mechanical Embolus Retrieval for Acute Ischemic Stroke, 7.01.094
Dynamic Spinal Stabilization, 7.01.096
Emergency Services: Auto Codes, 10.01.011A
NEW POLICIES/REVISIONS: Updated 5/12/08:
5/12/08: Policies and Operating Procedure Revised:
Ultrasound Accelerated Fracture Healing Device, 1.01.006
Spinal Cord and Deep Brain Stimulation, 7.01.025
Treatments for Urinary Incontinence, 7.01.041
Clinical Trial Mandate, Maryland and Virginia, 10.01.001A
NEW POLICIES/REVISIONS: Updated 4/21/08:
4/21/08: Policies and Operating Procedures Revised:
Medical Policy Reference Manual: Medical Policy and Operating Procedure
Development and Approval
Durable Medical Equipment with Attached Table, 1.01.001
Commode Chair, 1.01.028A
Fracture / Traction Frames and Associated Equipment, 1.01.031
Sphygmomanometer and Stethoscope, 1.01.047A
Sitz Bath, 1.01.052A
Automated Oscillometer Blood Pressure Monitors for Home Use, 1.01.071
Phototherapy, 2.01.007
Acupuncture, 2.01.048A
Colony Stimulaitng Factors, 5.01.003
Surgical Treatments of Varicosities, 7.01.082
Pharmocogenomic Testing for Warfarin Sensitivity, 11.01.038
NEW POLICIES/REVISIONS: Updated 4/14/08:
4/14/08: Policies Revised:
Xenon Chloride Excimer Laser Therapy for Treatment of Psoriasis, 2.01.049
Thoracic Electrical Bioimpedance Measurement, 2.02.003
Human Growth Hormone (HGH) Therapy for Children and Adults, 5.01.009
NEW POLICIES/REVISIONS: Updated 4/1/08:
4/1/08: Policy and Operating Procedure Revised:
Durable Medical Equipment with Attached Table, 1.01.001
Bathroom Aids, 1.01.021A
Bed Related Accessories, 1.01.022A
Cold Pad/Cold Pressure Therapy, 1.01.027A
Heating Pad, 1.01.032A
Restraints, 1.01.049A
Vaporizer, 1.01.055A
NEW POLICIES/REVISIONS: Updated 3/17/08:
3/17/08: Policies and Operating Procedure Revised:
Dehumidifier / Humidifier, 1.01.029A
Therapeutic Shoes for Individual with Diabetes, 1.02.015
Orthotic Devices and Orthopedic Appliances, 1.03.001
Orthotic Foot Inserts, 1.03.003
Ultrafiltration for Fluid Overload in Decompensated Heart Failure, 2.02.010
Radiofrequency Ablation of Malignant Tumors of the Liver, 7.01.073
NEW POLICIES/REVISIONS: Updated 3/13/08:
3/13/08: Policies and Operating Procedures Revised:
Thermography, 6.01.012
Selective Internal Radiation Therapy for Malignant Hepatic Tumors, 6.01.037
Obesity and Morbid Obesity, 7.01.036
Minimally Invasive Intervertebral Disc Decompression Procedures for Low Back Pain,
7.01.091
Intraspinous Vertebral Decompression Implantation for Spinal Stenosis, 7.01.092
Intravenous Patient-Controlled Analgesia (IV PCA), 9.01.002A
Moderate (Conscious) Sedation, 9.01.003A
NEW POLICIES/REVISIONS: Updated 2/25/08:
2/25/08: Operating Procedure Revised:
Bone-Anchored Hearing Aids, 7.01.003A
NEW POLICIES/REVISIONS: Updated 2/19/08:
2/19/08: Policies and Operating Procedures Revised:
Lumbar Roll Cushion, 1.01.035A
Massage Devices, 1.01.036A
Quantitative Sensory Testing for Peripheral Neuropathies, 2.01.059
CT Angiography for Diagnosing Coronary Artery Disease, 6.01.035
High Dose Chemotherapy / Radiation Therapy with Allogeneic Stem Cell Support,
7.03.003
Nonmyeloablative Allogeneic Hemopoietic Stem Cell Transplantation for Hematologic
Malignancies, 7.03.006
NEW POLICIES/REVISIONS: Updated 2/11/08:
2/11/08: Policies Revised:
Chelation Therapy, 2.01.027
Treatments for Urinary Incontinence, 7.01.041
Functional Neuromuscular Stimulation, 7.01.047
Cardiac Rehabilitation, 8.01.002
Pulmonary Rehabilitation Programs, 8.01.010
Genetic Testing for Canavan Disease, 11.01.027
NEW POLICIES/REVISIONS: Updated 2/6/08:
2/6/08: Policies Revised:
Archived Percutaneous Intradiscal Electrothermal Annuloplasty, 7.01.049
Percutaneous Intervertebral Thermal Annuloplasty Procedures for Low Back Pain,
7.01.101
NEW POLICIES/REVISIONS: Updated 1/22/08:
1/22/08: Policies and Operating Procedure Revised:
Air Cleaner / Purifier, 1.01.019A
Cervical Pillow, 1.01.025A
Intellectual Disability / Mental Retardation, 3.01.004
Attention Deficit Disorder (ADD) with or without Hyperactivity, 3.01.009
Global Maternity Care, 4.01.006A
Cochlear Implantation, 7.01.005
Cavernous Nerve Stimulation Device, 7.01.040
NEW POLICIES/REVISIONS: Updated 12/26/07:
12/26/07: Policies and Operating Procedure Revised:
Assisted Reproductive Technology (ART) Procedures: In Vitro Fertilization (IVF),
Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), 4.02.001
Assisted Reproductive Technology (ART): Artificial Insemination (AI) / Intrauterine
Insemination (IUI), 4.02.006A
Botulinum Toxin, 5.01.005
Intravenous Immune Globulin (IVIG) Therapy, 5.01.013
Magnetic Resonance Imaging (MRI) of the Breast, 6.01.022
Bronchial Thermoplasty for Control of Asthma, 7.01.102
Serum Biomarker Panels for Assessment of Hepatic Fibrosis, 11.01.037
NEW POLICIES/REVISIONS: Updated 12/3/07:
12/3/07: Policies and Operating Procedure Revised:
Durable Medical Equipment with Attached Tale, 1.01.001
Hyperbaric Oxygen Therapy, 2.01.004
Total Body Photography for Melanoma Risk Monitoring, 2.01.054A
External / Extracorporeal Counterpulsation (e.g.: ECP or EECP), 2.02.001
Electrical Bone Growth Stimulation, 7.01.007
High Dose Chemotherapy / Radiation Therapy with Autologous Stem Cell Support,
7.03.002
Hypo-osmotic Swelling Test for Sperm Function, 11.01.009
Testing for Tay-Sachs Disease, 11.01.026
NEW POLICIES/REVISIONS: Updated 11/26/07:
11/26/07: Policies Revised:
Dynamic Splinting Systems, 1.01.030
Blood-Derived Growth Factors for Wound Healing, 2.01.016
Biofeedback, 2.01.035
Cervical Vertebral Disc Replacement, 7.01.100
NEW POLICIES/REVISIONS: Updated 11/14/07:
11/14/07: Policies and Operating Procedure Revised:
Medical Policy Reference Manual:
Purpose
History
Guidelines for Use
Organization and Format
Dates Referenced in Medical Policies and Operating Procedures
Medical Policy Reference Manual and Archived Documents
Criteria for Developing a Written Medical Policy/Operation Procedure
Medical Policy and Operating Procedure Development and Approval
Implementation of Medical Policies and Operating Procedures
Definitions and Interpretive Guidelines
Transcatheter Arterial Chemoembolization for Malignant Tumors of the Liver, 2.03.003
Preventive Services, 10.01.003A
Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary
Carcinoma of the Thyroid, 11.01.007
Genetic Testing for Cystic Fibrosis, 11.01.025
NEW POLICY/REVISION: Updated 10/29/07:
10/29/07: Policies and Operating Procedure Revised:
Home Apnea Monitoring, 1.01.007
Cranial Orthotic Molding Devices, 1.03.002
Magnetic Resonance Imaging (MRI) of the Breast, 6.01.022
Magnetoencephalography and Magnetic Source Imaging, 6.01.036
Percutaneous Vertebroplasty and Kyphoplasty, 7.01.032
Lymphedema Therapy (Complex Decongestive Therapy), 8.01.014
Global Surgical Care Rules, 10.01.009A
NEW POLICY/REVISION: Updated 10/15/07:
10/15/07: Policies and Operating Procedure Revised:
Augmentative Communication Devices, 1.01.015A
Isolated Limb Perfusion, 2.03.006
Ultrasound (Echography) of the Spinal Canal and Contents, 6.01.024
Infrared Coagulation for Internal Hemorrhoids, 7.01.089
NEW POLICY/REVISION: Updated 10/01/07:
10/01/07: Policies Revised:
Neuropsychological Testing, 2.01.028
Monitoring of Regional Cerebral Blood Flow Using Implanted Cerebral Thermal
Infusion Probe, 2.01.058
Electrocardiographic Body Surface Mapping, 2.02.009
CT Angiography for Diagnosing Coronary Artery Disease, 6.01.035
Carotid Intima-Media Thickness Measurement to Assess Risk for Coronary
Artery Disease, 6.01.041
Spinal Cord and Deep Brain Stimulation, 7.01.025
Preconception Sex Selection Techniques, 11.01.015
NEW POLICY/REVISION: Updated 9/14/07:
9/14/07: Policies and Procedure Revised:
Tilt Table Test, 2.01.009
Implantable Hormone Replacement Pellets, 2.01.053
Assisted Reproductive Technology (ART) Procedures: In Vitro Fertilization (IVF), Gamete
Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), 4.02.001
Percutaneous Intradiscal Electrothermal Annuloplasty, 7.01.049
Emergency Services: Auto Codes, 10.01.011A
NEW POLICY/REVISION: Updated 9/4/07:
9/4/07: Policies Revised:
Home Apnea Monitoring, 1.01.007
Gait Analysis, 2.01.003
Erectile Dysfunction, 2.01.025
NEW POLICY/REVISION: Updated 8/17/07:
8/17/07: Policies and Procedures Revised:
Hypnosis/Hypnotherapy, 2.01.006A
Pervasive Developmental Disorders (e.g. Autism), 3.01.006
Multifetal Pregnancy Reduction, 4.02.003A
Whole Body Computed Tomography Scan as a Screening Test, 6.01.026
Computed Tomography as a Screening Test for Lung Cancer, 6.01.027
Computed Tomographic Colonography as a Test for Colon Cancer (Vitrtual Colonoscopy),
6.01.028
Diagnosis: Family History of, 10.01.010A
Salivary Melatonin Profile, 11.01.008
NEW POLICY/REVISION: Updated 8/6/07:
8/6/07: Policies Revised:
Hyperbaric Oxygen Therapy, 2.01.004
Exhaled Nitric Oxide Measurement for Treatment of Asthma, 2.01.057
Preimplantation Genetic Diagnosis, 4.02.007
Brachytherapy for Malignant Tumors, 6.01.020
Vertebral Disk Replacement/Lumbar Disk Prosthesis, 7.01.088
Speech Therapy, 8.01.005
NEW POLICY/REVISION: Updated 7/20/07:
7/20/07: Policies Revised:
Magnetic Resonance Spectroscopy, 6.01.034
Ultrasound Guided Cryoablation of Benign Fibroadenomas of the Breast, 7.01.085
Pulmonary Vein Ablation/Isolation for Atrial Fibrillation, 7.01.090
NEW POLICY/REVISION: Updated 7/9/07:
7/9/07: Policies and Procedure Revised:
Eyeglasses and Contact Lenses for Medical or Post-Operative Conditions, 2.01.039A
Stereotactic Radiosurgery (e.g. Gamma Knife®), 6.01.010
Donor Leukocyte Infusion, 7.03.005
NEW POLICY/REVISION: Updated 6/25/07:
6/25/07: Policies and Procedures Revised:
Extracorporeal Photopheresis, 2.01.051
Archived Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae, 7.01.026
Automatic Implantable Cardioverter Defibrillator (AICD), 7.01.087
Peripheral Arterial Disease Rehabilitation, 8.01.012
Anesthesia Services, 9.01.001A
Epidural / Intrathecal Analgesia, Post-Operative or Non-Surgical, 9.01.005A
Care of the Normal Newborn, 10.01.006
Pharmacogenomic and Serologic Metabolite Markers for Inflammatory Bowel Disease
Patients Treated with Azathioprine, 11.01.031
NEW POLICY/REVISION: Updated 6/11/07:
6/11/07: Policies Revised:
Correlated Audioelectric Cardiography, 2.02.008
Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging), 6.01.005
Electrical Impedance Scanning of the Breast, 6.01.040
Archived Cerebellar Stimulation / Pacemaker, 7.01.027
Lipoprotein-Associated Phospholipase A2 (Lp-PLA2), 11.01.036
Archived Anti-Gliadin and Anti-Endomysial Antibodies, 11.01.003
NEW POLICY/REVISION: Updated 6/4/07:
6/4/07: Policies and Procedures Revised:
Archived High-Dose Chemotherapy/Radiation Therapy with Autologous Bone
Marrow/Peripheral Stem Cell Support, 7.03.002A
Archived Allogeneic Bone Marrow Transplantation for Malignant and Non-Malignant
Conditions, 7.03.003A
Archived HPV Testing of Cervical Cytology, 11.01.021
Archived Plasma HIV RNA Quantification for HIV Infection, 11.01.022
Archived Identification of Microorganisms Using Nucleic Acid Probes, 11.01.023
NEW POLICY/REVISION: Updated 5/31/07:
5/31/07: Policies Revised:
Habilitative Services (MD and DC Mandates), 8.01.011A
Archived Endovascular Coagulation Procedure (VNUS® Closure™ System), 7.01.072
Archived Stapled Hemorrhoidectomy, 7.01.077
Archived Back School, 8.01.008
Archived Fetal Fibronectin Enzyme Immunoassay, 11.01.006
Archived HIV Viral Load Testing, 11.01.017
Archived Lactoferrin Tear MIcroassay, 11.01.018
NEW POLICY/REVISION: Updated 5/29/07:
5/29/07: Policies Revised:
Quantitative Electroencephalogram / Topographic Brain Mapping, 2.01.010
Tumor Markers, 11.01.001
Archived Sperm Antibodies, 11.01.011
Archived Sperm-Cervical Mucus Penetration (Huhner Test), 11.01.012
Archived Sperm Evaluation, Hamster Penetration Test, 11.01.013
Archived Paternal or Fetal Antigen Immunotherapy for Recurrent Fetal Loss, 11.01.014
Archived IGF (Insulin-like Growth Factor) Binding Proteins, 11.01.016
NEW POLICY/REVISION: Updated 5/14/07:
5/14/07: Policies and Procedures Revised:
Orthotic Devices and Orthopedic Appliances, 1.03.001
Eyeglasses and Contact Lenses for Medical or Post-Operative Conditions, 2.01.039A
Cosmetic and Preconstructive Surgery with Attached Companion Table, 7.01.017
Surgical Correction of Refractive Errors, 7.01.020A
Archived Maze Procedure, 7.01.014
Archived Implantable Infusion Pump, 7.01.024
Archived Laparoscopic Intestinal Surgery, 7.01.061
NEW POLICY/REVISION: Updated 4/27/07:
4/27/07: Policies and Procedure Revised:
Ambulatory Blood Pressure Monitoring, 2.02.006
Focused Ultrasound Ablation of Uterine Fibroids, 6.01.033
Archived Periurethral Injection of Collagen for the Treatment of Urinary Incontinence,
7.01.019
Archived Unna Boots, 7.01.021
Archived Selective Posterior Rhizotomy for the Spasticity of Cerebral Palsy, 7.01.028
Archived Sacral Nerve Stimulation for Treatment of Urinary Continence Disorders, 7.01.031
Archived Osteochondral Autograft Transfer System (OATS) Procedure, 7.01.034
Archived Insertable Cardiac Loop Event Monitor, 7.01.038
Archived Stereotactic Electroencephalography, 7.01.039
Archived Transmyocardial Laser Revascularization, 7.01.054
Archived Sclerotherapy for External Varicosities, 7.01.055
Archived Sclerotherapy for External Varicosities, 7.01.055A
Archived Transsexual Surgery, 7.01.070
Ventricular Assist Devices and Associated Services, 7.03.011
Low Level Laser Therapy for Musculoskeletal and Neuromuscular Conditions, 8.01.017
NEW POLICY/REVISION: Updated 4/16/07:
4/16/07: Policies Revised:
Wireless Aneurysm Sac Pressure Monitoring, 2.01.056
Transcranial Doppler Ultrasound, 6.01.007
Archived Dirsorders of the Prostate, 7.01.004
Archived Transjugular Intrahepatic Portosystemic Shunt (TIPS), 7.01.009
Percutaneous Intracranial Angioplasty With or Without Stent Insertion, 7.01.042
Balloon Sinuplasty, 7.01.044
Osteochondral Allograft Repair of the Ankle, 7.01.045
Wireless Capsule Endoscopy (Enteral Camera), 7.01.076
Work Hardening Programs, 8.01.007
NEW POLICY/REVISION: Updated 4/9/07:
4/9/07: Policies Revised:
Archived Positron Emission Tomography (PET) for Diagnosis and Treatment of Multiple
Sclerosis, 6.01.029
Archived Positron Emission Tomography (PET) for Diagnosis and Treatment of Alzheimer's
Disease, 6.01.030
Archived Angelchik™ Anti-Reflux Prosthesis, 7.01.002
Archived Audiant Bone Conductor, 7.01.003
Archived Transfusion Therapy for Hemolytic Disease of the Fetus and the Newborn,
7.01.012
NEW POLICY/REVISION: Updated 4/4/07:
4/4/07: Policies and Procedure Revised:
Transcutaneous Electrical Nerve Stimulators, (TENS), 1.01.010
Archived Herniography, 6.01.011
Archived Magnetic Resonance Angiography, 6.01.016
Archived Magnetic Resonance Guidance for Surgical Procedures, 6.01.021
Archived Single Photon Emission Computed Tomography (SPECT) Scan, 6.01.023
Archived Catheter Ablation for Cardiac Arrhythmias, 7.01.001
Percutaneous Electrical Nerve Stimulation (PENS), 7.01.023
Placental and Umbilical Cord Blood as a Source of Stem Cells, 7.03.004
Spinal Manipulation and Related Services, 8.01.003
Obstetrical Anesthesia Services, 9.01.006A
NEW POLICY/REVISION: Updated 3/19/07:
3/19/07: Policies and Procedure Revised:
Archived Blood Glucose Monitors (Glucometers), 1.01.004
Archived Vitamin B12 Injection, 2.01.012
Archived Esophageal pH Monitoring, 2.01.020
Archived Audiometric Testing, 2.01.030
Archived Rotary Chair / Harmonic Acceleration Test, 2.01.037
Archived Intracardiac Electrophysiologic Studies, 2.02.005
Real-Time Outpatient Cardiac Monitoring, 2.02.007
Archived Amniocentesis and Chorionic Villus Sampling (CVS), 4.01.002
Cervicography (Cervigram), 4.01.004A
Archived Ultrasound in Pregnancy, 4.01.007
Archived Hematopoietic Growth Factor (e.g. Epogen®, Procrit®, Aranesp®), 5.01.004
Archived Bone Density Studies, 6.01.001
NEW POLICY/REVISION: Updated 3/9/07:
3/9/07: Policies Revised:
Archived Signal-Averaged Electrocardiography (SAECG), 2.02.004
Archived Interleukin-2 (IL-2)/Aldesleukin (e.g., Proleukin), 5.01.011
Archived Intravascular Ultrasound (IVUS) Imaging, 6.01.004
Archived Pallidotomy for Treatment of Parkinson's Disease, 7.01.016
NEW POLICY/REVISION: Updated 3/5/07:
3/5/07: Policies and Procedures Revised:
Archived Ambulatory External Infusion Pumps, 1.01.009
Archived Extracorporeal Magnetic Innervation (ExMI) for Urinary Incontinence, 2.01.013
Archived Lyme Disease Vaccine (Lymerix®), 2.01.014A
Archived Rabies Treatment , 2.01.022
Archived Hemoperfusion, 2.01.032
Archived Therapeutic Phlebotomy, 2.01.033
Archived Electrical Stimulation of the Pelvic Floor for Stress Urinary Incontinence, 2.01.047
Archivec Ultrasound in Pregnancy, 4.01.007A
Uterine Artery Embolization for Fibroid Tumors (Leiomyomata), 4.01.008
Off-Label and Orphan Drug Use, 5.01.001
Archived Bone Density Studies, 6.01.001A
Standby Services, 10.01.004A
Medical Record Documentation Standards, 10.01.013A
NEW POLICY/REVISION: Updated 2/20/07:
2/20/07: Policies and Procedures Revised:
Durable Medical Equipment with Attached Table, 1.01.01
Infant Hearing Screening (MD, VA and DC Mandates), 2.01.46A
Assisted Reproductive Technology (ART) Procedures: IVF, GIFT, ZIFT, 4.02.01
Zoster Vaccine Live (Oka/Merck) (e.g. Zostavax®), 5.01.16
Mifepristone (e.g., Mifeprex, RU 486), 5.01.14A
Computerized Opthalmic Diagnostic Imaging, 6.01.31
Keratoprosthesis, 7.01.13
Total Hip Resurfacing, 7.01.33
Cryotherapy Dilation for Peripheral Arterial Disease, 7.01.99
Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease,
11.01.04
Molecular Genetic Expression Test for Identification of Heart Transplant Rejection, 11.01.34
Genetic Testing for Celiac Disease, 11.01.35
NEW POLICY/REVISION: Updated 1/22/07:
1/22/07: Policies and Procedures Revised:
Intravenous or Subcutaneous Histamine Therapy, 2.01.05
Cosmetic and Reconstructive Surgery, 7.01.17
Foot Care Services, 7.01.18
Extracorporeal Shock Wave Lithotripsy for Gallstones, 7.01.35
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion
Pump, 9.01.08A
Ambulance Services, 10.01.05
Genetic Testing for Inherited BRCA1 or BRCA2 Mutations, 11.01.02
NEW POLICY/REVISION: Updated 1/05/07:
1/05/07: Policies Revised:
Archived Avonex/Betaseron/Copaxone for the Treatment of Multiple Sclerosis, 5.01.06
Archived Adrenal-to-Brain Transplantation, 7.01.43
Archived Serum Toxicity Test, 11.01.10
NEW POLICY/REVISION: Updated 12/18//06:
12/18/06: Policies Revised:
Microvolt T-Wave Alternans, 2.02.02
Cryosurgical Ablation of Renal Cell Carcinoma, 7.01.98
Physical Therapy, 8.01.01
Assays of Genetic Expression in Tumor Tissue To Determine Prognosis in Breast Cancer
Patients, 11.01.32
NEW POLICY/REVISION: Updated 12/08//06:
12/08/06: Policies and Operating Procedures Revised:
Coverage for Hair Prosthesis, 1.01.13A
Allergy Testing, 2.01.23
Therapeutic Apheresis, 7.01.30
Occupational Therapy, 8.01.04
Global Surgical Care Rules, 10.01.09A
In Vitro Chemotherapeutic Drug Assays, 11.01.19
NEW POLICY/REVISION: Updated 11/27/06:
11/27/06: Policies Revised:
Botulinum Toxin, 5.01.05
Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine (e.g.,
Gardasil), 5.01.17
Bone Lengthening for Angular Deformities and Limb Length Disrepancies of Long Bones,
7.01.11
Interpositional Spacer for Osteoarthritis of the Knee Joint, 7.01.78
NEW POLICY/REVISION: Updated 11/10/06:
11/10/06: Policies and Operating Procedure Revised:
High Frequency Chest Wall Oscillation Vest, 1.01.12
Intraoperative Radiation Therapy, 6.01.17
Autologous Chondrocyte Implantation, 7.01.48
Prophylactic Mastectomy, 7.01.71
Wireless Capsule Endoscopy, 7.01.76
Laryngeal Denervation and Reinnervation for Laryngeal Dystonia, 7.01.79
Photocoagulation of Macular Drusen, 7.01.81
Human Organ Transplants, 7.03.01
Speculoscopy for Cervical Cancer Screening, 11.01.30A
NEW POLICY/REVISION: Updated 10/30/06:
10/30/06: Policies and Operating Procedure Revised:
Temporomandibular Joint Dysfunction, 2.01.21
Photodynamic Therapy, 2.03.07
Genetic Testing and Surveillance of Colon Cancer, 2.03.10
Assisted Reproductive Technology (ART): IVF, GIFT, ZIFT, 4.02.01
Assisted Reproductive Technology (ART): AI/IUI, 4.02.06A
Human Growth Hormone Therapy, 5.01.09
Lung Volume Reduction Surgery for Palliation of Severe Emphysema, 7.01.62
NEW POLICY/REVISION: Updated 10/13/06:
10/13/06: Policies and Operating Procedures Revised:
Adoptive Immunotherapy, 2.03.05
Image-Guided Surgery, 6.01.21A
Fetal Mesencephalic Transplantation for the Treatment of Parkinson's Disease, 7.01.10
Transpupillary Thermotheraopy, 7.01.80
Private Room, 10.01.07A
NEW POLICY/REVISION: Updated 10/02/06:
10/02/06: Policies and Operating Procedures Revised:
Continuous Passive Motion Device, 1.01.11
Coverage for Hearing Aids, 1.01.16A
Allergy Immunotherapy, 2.01.17
Video EEG Monitoring, 2.01.44
Screening for Colorectal Cancer, 2.03.11
Magnetic Resonance Neurography, 6.01.39
Anesthesia Consultation, 9.01.04A
Cytochrome P450 Genotyping, 11.01.33
NEW POLICY/REVISION: Updated 9/18/06:
9/18/06: Policies Revised:
Antineoplaston A Therapy, 2.03.09
Meniscal Allograft Transplantation, 7.01.15
Prolotherapy (Proliferative Therapy), 7.01.67
Recreational Activity as Physical Therapy (e.g., Golf, Hippotherapy), 8.01.09
NEW POLICY/REVISION: Updated 9/12/06:
9/12/06: Procedure Revised:
Emergency Services: Auto Codes, 10.01.11A
NEW POLICY/REVISION: Updated 9/05/06:
9/05/06: Policies Revised:
H-Wave Electrical Stimulation Devices For Home Use, 1.01.05
Electrocorticography, 2.01.11
Professional Nutritional Counseling, 2.01.50A
Spinal Manipulation Under Anesthesia, 7.01.84
Gastric Electrical Stimulation, 7.01.97
Vertebral Axial Decompression, 8.01.13A
Monochromatic Infrared Energy (MIRE) Therapy, 8.01.15
General Anesthesia for Dental Care (Md & Va Mandate), 9.01.07A
Attendance at Delivery, 10.01.02A
Surgical Assistants, 10.01.08A
NEW POLICY/REVISION: Updated 8/21/06:
8/21/06: Policies Revised:
Dynamic Posturography, 2.01.02
Hyperthermia in the Treatment of Cancer, 2.03.04
Thermal Capsulorrhaphy for Joint Instability, 7.01.29
Computer Assisted Navigational Techniques in Orthopedic Surgery, 7.01.50
Total Ankle Arthroplasty/Replacement, 7.01.93
Serum Proteomic Pattern Analysis Testing for Screening or Diagnosis of Ovarian Cancer,
11.01.28
Serum Antibody Marker Testing for Inflammatory Bowel Disease, 11.01.29
NEW POLICY/REVISION: Updated 8/7/06:
8/07/06: Policies Revised:
Naltrexone, Extended-Release Injectable Suspension, 5.01.15
Electron Beam Computed Tomography for the Heart, 6.01.03
Scintimammography, 6.01.25
Intensity Modulated Radiation Therapy (IMRT), 6.01.38
Vascular Angioscopy, 7.01.08
Cosmetic and Reconstruction Surgery, 7.01.17
Obesity and Morbid Obesity, 7.01.36
Dynamic Spinal Stabilization, 7.01.96
NEW POLICY/REVISION: Updated 7/24/06:
7/24/06: Policies Revised:
Pulse Electrical Stimulation Devices for Osteoarthritis of the Knee, 1.01.17
Phototherapy, 2.01.07
Orthoptics/Pleoptics (Vision Therapy), 2.01.15
Sensory Stimulation for Coma Patients, 2.01.24
Medical Foods for Treatment of Inherited Metabolic Disorders, 2.01.26
Ultrasound for the Evaluation of Paranasal Sinuses, 6.01.14
Oral-Facial Pathology or Trauma, 7.01.22
Electrophrenic Pacemaker, 7.01.37
Vagus Nerve Stimulation, 7.01.75
Endoscopic Therapies for Gastroesophageal Reflux, 7.01.95
Salivary Estriol Assessment of Risk for Preterm Labor, 11.01.20
NEW POLICY/REVISION: Updated 7/06/06:
7/06/06: Policies Revised:
Durable Medical Equipment with Attached Table, 1.01.01
Neutron Beam Radiotherapy, 6.01.18
Charged Particle (Proton or Helium Ion) Radiation, 6.01.19
NEW POLICY/REVISION: Updated 7/01/06:
7/01/06: Procedure Revised:
Diagnostic Eye Procedures with Companion Table, 2.01.38A
NEW POLICY/REVISION: Updated 6/28/06:
6/28/06: Policies Revised:
Hair Analysis, 2.01.43
Dynamic Cardiomyoplasty, 7.01.06
Percutaneous Lysis of Epidural Adhesions, 7.01.83
Anesthesia Services, 9.01.01A
NEW POLICY/REVISION: Updated 6/27/06:
6/27/06: Policies Revised:
Idiopathic Environmental Intolerance, 2.01.01
Treatments of Tinnitus, 2.01.19
Surface Electromyography, 2.01.31
Temperature Gradient Studies, 2.01.42
NEW POLICY/REVISION: Updated 6/13/06:
6/13/06: Policies Revised:
Enteral Nutrition Therapy, 1.02.03
Assisted Reproductive Technology (ART) Procedures: IVF, GIFT and ZIFT, 4.02.01
Mechanical Embolus Retrieval for Acute Ischemic Stroke, 7.01.94
NEW POLICY/REVISION: Updated 6/12/06:
6/12/06: Policies Revised:
Prosthetics, 1.04.01
Screening for Colorectal Cancer, 2.03.11
Spinal Cord and Deep Brain Stimulation, 7.01.25
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal
Conditions, 7.01.74
NEW POLICY/REVISION: Updated 5/26/06:
5/26/06: Policies Revised:
Ultrasound Accelerated Fracture Healing Device, 1.01.06
Rhinomanometry and Acoustic Rhinometry, 2.01.08
Carotid Artery Angioplasty and Stenting, 7.01.86
NEW POLICY/REVISION: Updated 5/22/06:
5/22/06: Policies and Procedure Revised:
Xenon Chloride Excimer Laser Therapy for Treatment of Psoriasis, 2.01.49
Global Maternity Care, 4.01.06A
Recurrent Pregnancy Loss (Recurrent Spontaneous Abortion), 4.02.08
Treatments for Urinary Incontinence, 7.01.41
Archived Stapled Hemorrhoidectomy, 7.01.77
NEW POLICY/REVISION: Updated 5/2/06:
5/2/06: Policies and Procedures Revised:
Elemental Nutrition for Treatment of Malabsorption Disorders, 1.02.02
Acupuncture, 2.01.48A
Thoracic Electrical Bioimpedance Measurement, 2.02.03
Clinical Trial Mandates, Maryland and Virginia, 10.01.01A
NEW POLICY/REVISION: Updated 4/24/06:
4/24/06: Policies Revised:
Neuromuscular Electrical Stimulation (NMES) Devices, 1.01.18
Radiofrequency Ablation of Malignant Tumors of the Liver, 7.01.73
NEW POLICY/REVISION: Updated 4/20/06:
4/20/06: Policies Revised:
Selective Internal Radiation Therapy for Malignant Hepatic Tumors, 6.01.37
Minimally Invasive Intervertebral Disc Decompression Procedures for Low Back Pain,
7.01.91
Intraspinous Vertebral Decompression Implantation for Spinal Stenosis, 7.01.92
Tumor Markers, 11.01.01
NEW POLICY/REVISION: Updated 4/19/06:
4/19/06: Policies Revised:
Colony Stimulating Factors, 5.01.03
Magnetic Resonance Imaging (MRI) of the Breast, 6.01.22
NEW POLICY/REVISION: Updated 04/14/06:
4/14/06: Policy Revised
Surgical Treatment of Varicosities, 7.01.82
NEW POLICIES/REVISIONS: Updated 03/27/06:
3/27/06: Policies Revised:
Allergy Immunotherapy, 2.01.17
Allergy Testing, 2.01.23
NEW POLICIES/REVISIONS: Updated 03/23/06:
3/23/06: Procedure Revised:
Moderate (Conscious) Sedation, 9.01.03A
NEW POLICIES/REVISIONS: Updated 03/21/06:
03/21/06: Policies and Procedure Revised:
Archived Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae, 7.01.26
Functional Neuromuscular Stimulation, 7.01.47
Intravenous Patient-Controlled Analgesia (IV PCA), 9.01.02A
Genetic Testing for Canavan Disease, 11.01.27
NEW POLICIES/REVISIONS: Updated 03/06/06:
03/06/06: Policies Revised:
Home Apnea Monitors, 1.01.07
Thermography, 6.01.12
Cardiac Rehabilitation, 8.01.02
Pulmonary Rehabilitation Programs, 8.01.10
NEW POLICIES/REVISIONS: Updated 02/21/06:
02/21/06: Policies and Procedures Revised:
Chelation Therapy, 2.01.27
Total Body Photography for Melanoma Risk Monitoring, 2.01.54A
Cochlear Implantation, 7.01.05
Habilitative Services (Maryland Mandate), 8.01.11A
NEW POLICIES/REVISIONS: Updated 02/17/06:
02/17/06: Policies and Procedures Revised:
Mental Retardation, 3.01.04
Attention Deficit Disorder (ADD) with or without Hyperactivity, 3.01.09
Positron Emission Tomography (PET), 6.01.32
Cavernous Nerve Stimulation Device, 7.01.40
NEW POLICIES/REVISIONS: Updated 01/18/06:
01/18/06: Policies and Procedures Revised:
Implantable Hormone Pellets, 2.01.53
Botulinum Toxin, 5.01.05
Intravenous Immune Globulin (IVIG) Therapy, 5.01.13
Cosmetic and Reconstructive Surgery, 7.01.17
Functional Neuromuscular Stimulation, Implantable, 7.01.47
NEW POLICIES/REVISIONS: Updated 01/17/06:
01/17/06: Policies and Procedures Revised:
External/Extracorporeal Counterpulsation (e.g.: ECP or EECP), 2.02.01
Assisted Reproductive Technology (ART): Artificial Insemination (AI)/ Intrauterine Insemination (IUI), 4.02.06A
Hypo-osmotic Swelling Test for Sperm Function, 11.01.09
NEW POLICIES/REVISIONS: Updated 01/11/06:
01/11/06: Policies and Procedures Revised:
Durable Medical Equipment with Attached Table, 1.01.01
Air Fluidized Beds, 1.01.02
Archived Audiometric Testing, 2.01.30
Continuous Glucose Monitoring, 2.01.45
NEW POLICIES/REVISIONS: Updated 01/10/06:
01/10/06: Policies and Procedures Revised:
Archived Herniography, 6.01.11
High Dose Chemotherapy/Radiation Therapy with Autologous Stem Cell Support, 7.03.02
High Dose Chemotherapy/ Radiation Therapy with Allogeneic Stem Cell Support, 7.03.03
Testing for Tay-Sachs Disease, 11.01.26
NEW POLICIES/REVISIONS: Updated12/19/05:
12/19/05: Policies and Procedures Revised:
Carbogen Therapy for Idiopathic Sudden Hearing Loss, 2.01.29
Low Osmolar Contrast Media, 6.01.13A
Cathepsin - D, 11.01.05
NEW POLICIES/REVISIONS: Updated11/29/05:
11/29/05: Policies and Procedures Revised:
Interleukin-2 (IL-2)/Aldesleukin (e.g., Proleukin), 5.01.11
Magnetoencephalography and Magnetic Source Imaging, 6.01.36
Pulmonary Vein Ablation / Isolation for Atrial Fibrillation, 7.01.90
Genetic Testing for Medullary Carcinoma of the Thyroid, 11.01.07
Genetic Testing for Cystic Fibrosis, 11.01.25
NEW POLICIES/REVISIONS: Updated11/28/05:
11/28/05: Policies and Procedures Revised:
Hyperbaric Oxygen Therapy, 2.01.04
Blood-Derived Growth Factors for Wound Healing, 2.01.16
Sleep Disorders, 2.01.18
Biofeedback, 2.01.35
Transcatheter Arterial Chemoembolization for Malignant Tumors of the Liver, 2.03.03
NEW POLICIES/REVISIONS: Updated11/14/05:
11/14/05: Procedures Revised:
Surgical Correction of Refractive Errors, 7.01.20A
Preventive Services, 10.01.03A
NEW POLICIES/REVISIONS: Updated11/7/05:
11/7/05: Policies and Procedures Revised:
Computerized Ophthalmic Diagnostic Imaging, 6.01.31
Percutaneous Vertebroplasty and Kyphoplasty, 7.01.32
Obesity and Morbid Obesity, 7.01.36
Infrared Coagulation for Hemorrhoids, 7.01.89
NEW POLICIES/REVISIONS: Updated10/18/05:
10/18/05: Policies and Procedures Revised:
Isolated Limb Perfusion, 2.03.06
Ultrasound (Ecography) of the Spinal Canal and Contents, 6.01.24
Percutaneous Intradiscal Annuloplasty (IDET, IDEA), 7.01.49
Lymphedema Therapy (Complex Decongestive Therapy), 8.01.14A
Ericsson Sex Pre-Selection Technique, 11.01.15
NEW POLICIES/REVISIONS: Updated 09/29/05:
09/29/05: Policies Revised:
Progesterone Administration for the Prevention of Preterm Labor, 4.01.09
Human Growth Hormone (HGH) Therapy for Children and Adults, 5.01.09
CT Angiography for Diagnosing Coronary Artery Disease, 6.01.35
NEW POLICIES/REVISIONS: Updated 09/19/05:
09/19/05: Policies and Procedures Revised:
Neuropsychological Testing, 2.01.28
Emergency Services: Auto Codes, 10.01.11A
NEW POLICIES/REVISIONS: Updated 09/02/05:
09/02/05: Policies Revised:
Real-Time Outpatient Cardiac Monitoring, 2.02.07
Whole Body Computed Tomography Scan as a Screening Test, 6.01.26
Computed Tomography as a Screening Test for Lung Cancer, 6.01.27
Computed Tomographic Colonography as a Test for Colon Cancer (Virtual Colonoscopy),
6.01.28
Salivary Melatonin Profile, 11.01.08
NEW POLICIES/REVISIONS: Updated 08/10/05:
08/10/05: Policies Revised:
Cranial Orthotic Molding Devices, 1.03.02
Sleep Disorders, 2.01.18
Erectile Dysfuntion, 2.01.25
Assays of Genetic Expression in Tumor Tissue to Determine Prognosis in Breast Cancer
Patients, 11.01.32
NEW POLICIES/REVISIONS: Updated 07/18/05:
07/18/05: Policies Revised:
Gait Analysis, 2.01.03
Tilt Table Test, 2.01.09
Genetic Testing and Surveillance of Colon Cancer, 2.03.10
Multifetal Pregnancy Reduction, 4.02.03A
Diagnosis: Family History of, 10.01.10A
NEW POLICIES/REVISIONS: Updated 07/11/05:
07/11/05: Policies Revised:
Extracorporeal Photopheresis, 2.01.51
Brachytherapy for Malignant Tumors, 6.01.20
Treatments for Urinary Incontinence, 7.01.41
Speech Therapy, 8.01.05
NEW POLICIES/REVISIONS: Updated 07/07/05:
07/07/05: Procedures Revised:
Augmentative Communication Devices, 1.01.15A
Hypnosis/Hypnotherapy, 2.01.06A
Diagnostic Eye Procedures with Companion Table, 2.01.38A
NEW POLICIES/REVISIONS: Updated 06/27/05:
06/27/05: Policies and Procedures Revised:
Donor Leukocyte Infusions, 7.03.05
Peripheral Arterial Disease Rehabilitation, 8.01.12
Anesthesia Services, 9.01.01A
NEW POLICIES/REVISIONS: Updated 06/14/05:
06/14/05: Policies Revised:
Durable Medical Equipment with Attached Table, 1.01.01
Assisted Reproductive Technology (ART) Procedures: IVF, GIFT, ZIFT, 4.02.01
Stereotactic Radiosurgery (e.g. Gamma Knife®), 6.01.10
NEW POLICIES/REVISIONS: Updated 06/13/05:
06/13/05: Policies and Procedures Revised:
Magnetic Resonance Spectroscopy, 6.01.34
Obesity and Morbid Obesity, 7.01.36
Automatic Implantable Cardioverter Defibrillator (AICD), 7.01.87
Vertebral Disk Replacement/Lumbar Disk Prosthesis, 7.01.88
Pharmacogenomic and Serologic Metabolite Markers for Inflammatory Bowel Disease Patients, 11.01.31
Treated with Azathioprine, 11.01.31
NEW POLICIES/REVISIONS: Updated 06/10/05:
06/10/05: Policies and Procedures Revised:
Wheelchairs and Manual or Power Operated Vehicles, 1.01.14A
Epidural / Intrathecal Analgesia, Post-Operative or Non-Surgical, 9.01.05A
Care of the Normal Newborn, 10.01.06
NEW POLICIES/REVISIONS: Updated 05/23/05:
05/23/05: Policies and Procedures Revised:
Orthotic Foot Inserts, 1.03.03
Home Based, Real Time Cardiac Surveillance System, 2.02.07
Pervasive Developmental Disorders (e.g. Autism), 3.01.06
NEW POLICIES/REVISIONS: Updated 04/28/05:
04/28/05: Policies and Procedures Revised:
Orthotic Devices and Orthopedic Appliances, 1.03.01
Digital Analysis of Electroencephalogram and Topographic Brain Mapping, 2.01.10
Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging), 6.01.05
Electrical Bone Growth Stimulation, 7.01.07
Cerebellar Stimulation/Pacemaker, 7.01.27
NEW POLICIES/REVISIONS: Updated 04/15/05:
04/15/05: Policies and Procedures Revised:
Photodynamic Therapy, 2.03.07
Focused Ultrasound Ablation of Uterine Fibroids, 6.01.33
Ventricular Assist Devices and Associated Services, 7.03.11
Low Level Laser Therapy for Musculoskeletal and Neuromuscular Conditions, 8.01.17
NEW POLICIES/REVISIONS: Updated 04/14/05:
04/14/05: Policies and Procedures Revised:
Transcutaneous Electrical Nerve Stimulators (TENS), 1.01.10
Eyeglasses and Contact Lenses for Medical or Post-Operative Conditions, 2.01.39A
Ambulatory Blood Pressure Monitoring, 2.02.06
Lymphedema Therapy (Complex Decongestive Therapy), 8.01.14A
NEW POLICIES/REVISIONS: Updated 04/04/05:
04/04/05: Policies and Procedures Revised:
Sleep Disorders, 2.01.18
Acupuncture, 2.01.48A
Percutaneous Electrical Nerve Stimulation (PENS), 7.01.23
Work Hardening Programs, 8.01.07
NEW POLICIES/REVISIONS: Updated 03/16/05:
03/16/05: Policies and Procedures Revised:
Transcranial Doppler Ultrasound, 6.01.07
Computerized Ophthalmic Diagnostic Imaging, 6.01.31
Oral-Facial Pathology or Trauma, 7.01.22
Placental and Umbilical Cord Blood as a Source of Stem Cells, 7.03.04
Sedation With or Without Analgesia (Conscious Sedation), 9.01.03A
NEW POLICIES/REVISIONS: Updated 03/01/05:
03/01/05: Policies and Procedures Revised:
Cervicography (Cervigram), 4.01.04A
Uterine Artery Embolizat8on for Fibroid Tumors (Leiomyomata), 4.01.08
Low Osmolar Contrast Media, 6.01.13A
Carotid Artery Angioplasty and Stenting, 7.01.86
Spinal Manipulation and Related Services, 8.01.03
Speculoscopy for Cervical Cancer Screening, 11.01.30A
NEW POLICIES/REVISIONS: Updated 02/10/05:
02/10/05: Policies and Procedures Revised:
Off Label and Orphan Drug Use, 5.01.01
Obstetrical Anesthesia Services, 9.01.06A
Standby Services, 10.01.04A
Medical Record Documentation Standards, 10.01.13A
NEW POLICIES/REVISIONS: Updated 02/09/05:
02/09/05: Policies and Procedures Revised:
Medical Policy Reference Manual
Purpose
History
Guidelines for Use
Organization and Format
Dates Referenced in Medical Policies and Operating Procedures
Medical Policy Reference Manual and Archived Documents
Criteria for Developing a Written Medical Policy/Operation Procedure
Medical Policy and Operating Procedure Development and Approval
Implementation of Medical Policies and Operating Procedures
Definitions and Interpretive Guidelines
NEW POLICIES/REVISIONS: Updated 1/19/05:
01/19/05: Policies and Procedures Revised:
Infant Hearing Screening, 2.01.46A
Mifepristone (e.g. Mifeprex, RU 486), 5.01.14A
Genetic Testing for Inherited BRCA1 or BRCA2 Mutations, 11.01.02
Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease, 11.01.04
NEW POLICIES/REVISIONS: Updated 12/23/04:
12/23/04: Policies Revised:
Foot Care Services, 7.01.18
Physical Therapy, 8.01.01
Occupational Therapy, 8.01.04
Ambulance Services, 10.01.05
NEW POLICIES/REVISIONS: Updated 12/13/04:
12/13/04: Policies Revised:
Coverage for Hair Prostheses, 1.01.13A
Orthoptics/Pleoptics (Vision Therapy), 2.01.15
Allergy Testing, 2.01.23
Neuropsychological Testing, 2.01.28
In Vitro Chemotherapeutic Drug Assays, 11.01.19
NEW POLICIES/REVISIONS: Updated 11/30/04:
11/30/04: Policies Revised:
Microvolt T-Wave Alternans, 2.02.02
Cosmetic and Reconstructive Surgery, 7.01.17
Therapeutic Apheresis (Plasmapheresis), 7.01.30
Ultrasound Guided Cryoablation of Benign Fibroadenomas of the Breast, 7.01.85
NEW POLICIES/REVISIONS: Updated 11/24/04:
11/24/04: Policies Revised:
High Frequency Chest Wall Oscillation Vest, 1.01.12
Interpositional Spacer for Osteoarthritis of the Knee Joint, 7.01.78
Laryngeal Denervation and Reinnervation for Laryngeal Dystonia, 7.01.79
Global Surgical Care Rules, 10.01.09A
NEW POLICIES/REVISIONS: Updated 10/28/04:
10/28/04: Policies Revised:
Global Maternity Care, 4.01.06A
Autologous Chondrocyte Transplantation, 7.01.48
Human Organ Transplants, 7.03.01
NEW POLICIES/REVISIONS: Updated 10/20/04:
10/20/04: Policies Revised:
Surgical Correction of Refractive Errors, 7.01.20A
Prophylactic Mastectomy, 7.01.71
Transpupillary Thermotherapy, 7.01.80
Photocoagulation of Macular Drusen, 7.01.81
NEW POLICIES/REVISIONS: Updated 10/19/04:
10/19/04: Policies Revised:
Temporomandibular Joint (TMJ) Dysfunction, 2.01.21
Adoptive Immunotherapy for Renal Cell Carcinoma, 2.03.05
Intraoperative Radiation Therapy, 6.01.17
Ilizarov Bone Lengthening Procedure, 7.01.11
Lung Volume Reduction Surgery for Palliation of Severe Emphysema, 7.01.62
NEW POLICIES/REVISIONS: Updated 09/30/04:
09/30/04: Policies Revised:
Image Guided Surgery, 6.01.21A
Keratoprosthesis, 7.01.13
Computer Assisted Navigational Techniques in Orthopedic Surgery, 7.01.50
Monochromatic Infrared (MIRE) Therapy, 8.01.15
Private Room, 10.01.07A
NEW POLICIES/REVISIONS: Updated 09/29/04:
09/29/04: Policies Revised:
Photodynamic Therapy, 2.03.07
Genetic Testing and Surveillance of Colon Cancer, 2.03.10
Assisted Reproductive Technology (ART) Procedures: In Vitro Fertilization (IVF), Gamete
Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), 4.02.01
Assisted Reproductive Technology (ART): Artificial Insemination (AI) / Intrauterine
Insemination (IUI), 4.02.06A
Preimplantation Genetic Diagnosis, 4.02.07
NEW POLICIES/REVISIONS: Updated 09/14/04:
09/14/04: Policies Revised:
Allergy Immunotherapy, 2.01.17
Fetal Mesencephalic Transplantation for the Treatment of Parkinson's Disease, 7.01.10
Prolotherapy (Proliferative Therapy), 7.01.67
Wireless Capsule Endoscopy (Enteral Camera), 7.01.76
NEW POLICIES/REVISIONS: Updated 09/02/04:
09/02/04: Policies Revised:
Coverage for Hearing Aids (Maryland Mandate), 1.01.16A
Video Electroencephalographic (EEG) Monitoring, 2.01.44
Human Growth Hormone (HGH) Therapy for Children and Adults, 5.01.09
Meniscal Allograft Transplantation, 7.01.15
Spinal Manipulation Under Anesthesia, 7.01.84
NEW POLICIES/REVISIONS: Updated 09/01/04:
09/01/04: Policies Revised:
Archived Positron Emission Tomography (PET) for Diagnosis and Treatment of Multiple
Sclerosis, 6.01.29
Archived Positron Emission Tomography (PET) for Diagnosis and Treatment of Alzheimer's
disease, 6.01.30
Positron Emission tomography (PET), 6.01.32
Emergency Services: Auto Codes, 10.01.11A
NEW POLICIES/REVISIONS: Updated 08/24/04:
08/24/04: Policies Revised:
Antineoplaston A Therapy, 2.03.09
Recreational Activity as Physical Therapy (e.g., Golf, Hippotherapy), 8.01.09
Anesthesia Consultation, 9.01.04A
Ambulance Services, 10.01.05
NEW POLICIES/REVISIONS: Updated 08/17/04:
08/17/04: Policies Revised:
Orthotic Devices and Orthopedic Appliances, 1.03.01
Electrocorticography, 2.01.11
Professional Nutritional Counseling, 2.01.50A
Hyperthermia in the Treatment of Cancer, 2.03.04
Foot Care Services, 7.01.18
NEW POLICIES/REVISIONS: Updated 08/10/04:
08/10/04: Policies Revised:
Continuous Passive Motion (CPM) Device, 1.01.11
Pulsed Electrical Stimulation Device for Osteoarthritis of the Knee, 1.01.17
Vertebral Axial Decompression, 8.01.13A
Serum Proteomic Pattern Analysis Testing for Screening or Diagnosis of
Ovarian Cancer, 11.01.28
Serum Antibody Marker Testing for Inflammatory Bowel Disease, 11.01.29
NEW POLICIES/REVISIONS: Updated 07/27/04:
07/27/04: Policies Revised:
Elemental Nutrition for Treatment of Malabsorption Disorders, 1.02.02
Enteral Nutrition Therapy, 1.02.03
Dynamic Posturography, 2.01.02
Ventricular Assist Devices, 7.03.11
General Anesthesia for Dental Care (Maryland and Virginia Mandates), 9.01.07A
Attendance at Delivery, 10.01.02A
Surgical Assistants, 10.01.08A
NEW POLICIES/REVISIONS: Updated 07/12/04:
07/12/04: Policies Revised:
Archived Ambulatory External Infusion Pumps, 1.01.09
Scintimammography, 6.01.25
Occupational Therapy, 8.01.04
NEW POLICIES/REVISIONS: Updated 06/16/04:
06/16/04: Policies Revised:
Sensory Stimulation of Coma Patients, 2.01.24
Electron Beam Computed Tomography (Ultrafast CT) (e.g., HeartScan®), 6.01.03
Ultrasound for the Evaluation of Paranasal Sinuses (e.g., Echosine), 6.01.14
Care of the Normal Newborn, 10.01.06
Salivary Estriol for Assessment of Risk for Preterm Labor (SalEst®), 11.01.20
NEW POLICIES/REVISIONS: Updated 06/09/04:
06/09/04: Policies Revised:
Treatments of Tinnitus, 2.01.19
Surface Electromyography (EMG), 2.01.31
Charged Particle (Proton or Helium Ion) Radiation Therapy, 6.01.19
Percutaneous Lysis of Epidural Adhesions, 7.01.83
NEW POLICIES/REVISIONS: Updated 05/21/04:
05/21/04: Policies Revised:
Idiopathic Environmental Intolerances, 2.01.01
Medical Foods for Treatment of Inherited Metabolic Disorders, 2.01.26
Neutron Beam Radiotherapy, 6.01.18
Obesity and Morbid Obesity, 7.01.36
Electrophrenic Pacemaker, 7.01.37
Surgical Treatment of Varicosities, 7.01.82
NEW POLICIES/REVISIONS: Updated 05/13/04:
05/13/04: Policies Revised:
Rhinomanometry and Acoustic Rhinometry, 2.01.08
Temperature Gradient Studies, 2.01.42
Hair Analysis, 2.01.43
Screening for Colorectal Cancer, 2.03.11
Dynamic Cardiomyoplasty, 7.01.06
Spinal Cord and Deep Brain Stimulation, 7.01.25
Vagus Nerve Stimulation, 7.01.75
NEW POLICIES/REVISIONS: Updated 05/06/04:
05/06/04: Policies Revised:
Archived Extracorporeal Magnetic Innervation (ExMI) for Urinary Incontinence, 2.01.13
Archived Electrical Stimulation of the Pelvic Floor for Stress Urinary Incontinence, 2.01.47
Thoracic Electrical Bioimpedance Measurement, 2.02.03
Archived Periurethral Injection of Collagen for the Treatment of Urinary Incontinence, 7.01.19
Archived Sacral Nerve Stimulation (Interstim) for Treatment of Urinary Continence Disorders,
7.01.31
Treatments for Urinary Incontinence, 7.01.41
Wireless Capsule Endoscopy (Enteral Camera), 7.01.76
NEW POLICIES/REVISIONS: Updated 04/29/04:
04/29/04: Policies and Procedures Revised:
Phototherapy, 2.01.07
Botulinum Toxin (e.g. Botox, Oculinum, Myobloc), 5.01.05
Vascular Angioscopy, 7.01.08
Functional Neuromuscular Stimulation, Implantable, 7.01.47
Staple Hemorrhoidectomy, 7.01.77
Obstetrical Anesthesia Services, 9.01.06A
Clinical Trial Mandates, Maryland and Virginia, 10.01.01A
NEW POLICIES/REVISIONS: Updated 04/14/04:
04/14/04: Policies and Procedures Revised:
Home Apnea Monitors, 1.01.07
Prosthetics, 1.04.01
Excimer Laser Treatment for Psoriasis, 2.01.49
Global Maternity Care, 4.01.06A
Recurrent Pregnancy Loss, 4.02.08
Archived Paternal or Fetal Antigen Immunotherapy for Recurrent Fetal Loss, 11.01.14
NEW POLICIES/REVISIONS: Updated 03/18/04:
03/18/04: Policies Revised:
Ultrasound Accelerated Fracture Healing Device (e.g. Exogen), 1.01.06
Elemental Nutrition for Treatment of Malabsorption Disorders, 1.02.02
Enteral Nutrition Therapy, 1.02.03
Magnetic Resonance Imaging (MRI) of the Breast, 6.01.22
Radiofrequency Ablation of Malignant Tumors of the Liver, 7.01.73
Extracorporeal Shock Wave Therapy for Chronic Heel Pain, 7.01.74
Testing for Tay-Sachs Disease, 11.01.26
Genetic Testing for Canavan Disease, 11.01.27
NEW POLICIES/REVISIONS: Updated 03/01/04:
03/01/04: Policies and Procedures Revised:
Thermography, 6.01.12
Archived Disorders of the Prostate, 7.01.04
Cavernous Nerve Stimulation Device, 7.01.40
Intravenous Patient Controlled Analgesia, 9.01.02A
Emergency Services: Auto Codes, 10.01.11A
Tumor Markers, 11.01.01
Hypo-osmotic Swelling Test for Sperm Function, 11.01.09
NEW POLICIES/REVISIONS: Updated 01/30/04:
01/30/04: Procedure Revised:
Diagnostic Eye Procedures with Companion Table, 2.01.38A
NEW POLICIES/REVISIONS: Updated 01/27/04:
01/27/04: Policies and Procedures Revised:
Cochlear Implant, 7.01.05
Surgical Treatment of Varicosities, 7.01.82
Anesthesia Services, 9.01.01A
Attendance at Delivery, 10.01.02A
Medical Record Documentation Standards, 10.01.13A
NEW POLICIES/REVISIONS: Updated 01/12/04:
01/12/04: Policies and Procedures Revised:
Mental Retardation, 3.01.04
Pervasive Developmental Disorders (e.g., Autism), 3.01.06
Attention Deficit Disorder (ADD) with or without Hyperactivity, 3.01.09
Oral-Facial Pathology or Trauma, 7.01.22
Arthroscopic Thermocapsular Shrinkage for Joint Capsule, 7.01.29
Habilitative Services, 8.01.11A
NEW POLICIES/REVISIONS: Updated 12/31/03:
01/01/04: Procedure revised:
Global Maternity Care, 4.01.06A
NEW POLICIES/REVISIONS: Updated 12/17/03
12/17/03: Policies Revised:
Chelation Therapy, 2.01.27
External/Extracorporeal Counterpulsation (e.g., ECP/EECP), 2.02.01
Colony Stimulating Factors, 5.01.03
Botulinum Toxin (e.g., Botox, Oculinum), 5.01.05
Cardiac Rehabilitation, 8.01.02
Pulmonary Rehabilitation, 8.01.10
NEW POLICIES/REVISIONS: Updated 11/14/03
11/14/03: Policies Revised:
Air Fluidized Beds, 1.01.02
Sleep Disorders, 2.01.18
Archived Hematopoietic Growth Factor, 5.01.04
Intravenous Immune Globulin (IVIG) Therapy, 5.01.13
Herniography, 6.01.11
Computerized Ophthalmic Diagnostic Imaging, 6.01.31
Surgical Treatment of Varicosities, 7.01.82
Cathepsin-D, 11.01.05
Archived IGF (Insulin-like Growth Factor) Binding Proteins, 11.01.16
NEW POLICIES/REVISIONS: Updated 11/01/03
11/01/03: Procedure Revised:
Anesthesia Services, 9.01.01A
NEW POLICIES/REVISION: Updated 10/09/03
10/09/03: Policy Revised:
Human Growth Hormone (HGH) Therapy for Children and Adults, 5.01.09
New Procedure:
Lymphedema Therapy (Complex Decongestive Therapy), 8.01.14A
NEW POLICIES/REVISION: Updated 9/15/03
9/15/03: Policies Procedures Reviewed or Revised
H-Wave Electrical Stimulation (e.g., VST -100® Myodynamic Prosthesis), 1.01.05
Carbogen Therapy for Sudden Hearing Loss, 2.01.29
Biofeedback, 2.01.35
Chemoembolization for Malignant Tumors of the Liver, 2.03.03
Stereotactic Radiosurgery (e.g. Gamma Knife), 6.01.10
Preventive Services, 10.01.03A
Genetic Testing for Medullary Carcinoma of the Thyroid, 11.01.07
New Policies/Procedures:
Obstetrical Anesthesia Services, 9.01.06A
Genetic Testing for Cystic Fibrosis, 11.01.25
NEW POLICIES/REVISION: Updated 9/9/03
9/9/03: Policies/Procedures Reviewed or Revised
Hypnosis/Hypnotherapy, 2.01.06A
Growth Factors for Wound Healing, 2.01.16
Interleukin-2 (IL-2)/Aldesleukin (e.g., Proleukin), 5.01.11
Percutaneous Vertebroplasty, 7.01.32
High-Dose Chemotherapy/Radiation THerapy with
Autologous Bone Marrow/Peripheral Support 7.03.02
Allogeneic Bone Marrow Transplantation for Malignant and Non-Malignant Conditions 7.03.03
NEW POLICIES/REVISION: Updated 7/31/03
7/31/03: Policies/Procedures Reviewed or Revised
Ultrasound (Echography) of the Spinal Canal and Contents, 6.01.24
Scanning with Electron Beam Computed Tomography (e.g. Virtual Physical), 6.01.26
Scanning the Lungs with Electron Beam Computed Tomography (e.g. Virtual Lung Scan) , 6.01.27
Scanning the Colon with Electron Beam Computed Tomography (e.g. Virutal Colonoscopy), 6.01.28
Intradiscal Electrothermal Therapy, 7.01.49
Surgical Treatment of Varicosities, 7.01.82
New Policies/Procedures:
Percutaneous Lysis of Epidural Adhesions, 7.01.83
NEW POLICIES/REVISION: Updated 7/29/03
7/29/03: Policies/Procedures Reviewed or Revised
Isolated Limb Perfusion, 2.03.06
Human Growth Hormone (HGH) Therapy for Children and Adults, 5.01.09
Continuous Glucose Monitoring, 2.01.45
Paternal or Fetal Antigen Immunotherapy for Recurrent Fetal Loss, 11.01.14
Ericsson Sex Pre-Selection Technique with Artificial Insemination, 11.01.15
Audiometric Testing, 2.01.30
Archived Anti-Gliadin and Anti-Endomysial Antibodies, 11.01.03
NEW POLICIES/REVISION: Updated 7/25/03
07/25/03: Policies/Procedures Reviewed or Revised
Gait Analysis, 2.01.03
Hyperbaric Oxygen Therapy (HBO2), 2.01.04
Tilt Table Test, 2.01.09
Ventricular Assist Devices, Insertion and Removal of, 7.03.11
Salivary Melatonin Profile, 11.01.08
NEW POLICIES/REVISIONS: Updated 7/08/03
07/08/03: Policies/Procedures Reviewed or Revised:
Cranial Orthotic Molding Device, i.e. Dynamic Orthotic Cranioplasty®, 1.03.02
Erectile Dysfunction, 2.01.25
Acupuncture, 2.01.48A
Archived Insertable Cardiac Loop Monitor (e.g., Reveal®), 7.01.38
NEW POLICIES/REVISIONS: Updated 7/01/03
07/01/03: Policies/Procedures Reviewed or Revised:
Augmentative Communication Devices, 1.01.15A
Global Maternity Care, 4.01.06A
Multifetal Pregnancy Reduction, 4.02.03A
Brachytherapy for Malignant Tumors, 6.01.20
Donor Leukocyte Infusion, 7.03.05
Diagnosis: Family History of, 10.01.10A
Obesity and Morbid Obesity, 7.01.36
New Policies/Procedures:
NEW POLICIES/REVISION: Updated 5/29/03
05/29/03: Policies/Procedures Reviewed or Revised:
Neuropsychological Testing, 2.01.28
Stereotactic Radiosurgery, 6.01.10
Surgical Treatment of Varicosities, 7.01.82
Peripheral Vascular Disease Rehabilitation, 8.01.12
NEW POLICIES/REVISION: Updated 5/14/03
05/14/03: Policies/Procedures Reviewed or Revised
Anesthesia Services, Procedure 9.01.01A
Assosted Reproductive Technology (ART) Procedures, Procedure 4.02.01A
NEW POLICIES/REVISION: Updated 5/07/03
05/07/03: Policies/Procedures Reviewed or Revised:
Wheelchairs and Manual or Power Operated Vehicles, Procedure 1.01.14A
Cervicography (Cervigram), Procedure 4.01.04A
Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging), Policy 6.01.05
Electrical Bone Growth Stimulation, Policy 7.01.07
Cosmetic and Reconstructive Surgery, Policy 7.01.17
Cerebellar Stimulation/Pacemaker, Policy 7.01.27
Archived Selective Posterior Rhizotomy for the Spasticity of Cerebral Palsy, Policy 7.01.28
Solid Human Organ Transplants, Policy 7.03.01
Epidural/Intrathecal Analgesia, Post-Operative or Non-surgical, Procedure 9.01.05A
NEW POLICIES/REVISION: Updated 4/17/03
04/17/03: Policies/Procedures Reviewed or Revised:
Durable Medical Equipment with Attached Table, Policy 1.01.01
Orthotic Devices and Orthopedic Appliances, Policy 1.03.01
Orthotic Foot Inserts, Policy1.03.03
Phototherapy, Policy 2.01.07
Archived Laparoscopic Intestinal Surgery, Policy 7.01.61
Work Hardening Programs, Policy 8.01.07
NEW POLICIES/REVISION: Updated 4/15/03
04/15/03: Policies/Procedures Reviewed or Revised:
Digital Analysis of Electroencephalogram and Topographic Brain Mapping, Policy 2.01.10
Transcranial Doppler Ultrasound, Policy 6.01.07
Placental and Umbilical Cord Blood as a Source of Stem Cells, Policy 7.03.04
Standby Services, Procedure 10.01.04A
NEW POLICIES/REVISION: Updated 3/13/03
03/13/03: Policies/Procedures Reviewed and or Revised:
Sleep Disorders, Policy 2.01.18
Eyeglasses and Contact Lenses for Medical opr Post-Operative Conditions, Procedure 2.01.39A Uterine Artery Embolization for Fibroid Tumors (Leiomyomata), Policy 4.01.08
Off-Label and Orphan Drug Use, Policy 5.01.01
Mifepriston (e.g.Mifeprex ™,RU486) Policy 5.01.14A
Percutaneous Electrical Nerve Stimulation, Policy 7.01.23
Speech Therapy, Policy 8.01.05
In VItro Chemotherapeutic Drug Assays (Oncotech EDR® )
NEW POLICIES/REVISION -- Updated 2/24/03
2/24/03: Policies/Procedures Reviewed and or Revised:
Infant Hearing Screening, Procedure 2.01.46A
Orthoptic/Pleoptics (Vision Therapy), Policy 2.01.15
Genetic Testing for Inherited BRCA1 or BRCA2 Mutations, Policy 11.01.02
Diagnostic Testing for Alzheimer's Disease, Policy 11.01.04
NEW POLICIES/REVISION -- Updated 1/30/03
1/30/03: Policies/Procedures Reviewed and/or Revised:
Diagnostic Eye Procedures, Procedure 2.01.38A
Ambulance Services, Policy 10.01.05
New Policies/Procedures:
Computerized Ophthalmic Diagnostic Imaging, Policy 6.01.31
NEW POLICIES/REVISION -- Updated 1/17/03
1/17/03: Policies/Procedures Reviewed and/or Revised:
Ambulatory Blood Pressure Monitoring, Policy 2.02.06
Archived Sclerotherapy for External Varicosities, Policy 7.01.55
Archived Sclerotherapy for External Varicosities, Procedure 7.01.55A
Archived Endvascular Coagulation Procedure (VNUS® Closure ™ System), Policy 7.01.72
Spinal Manipulation and Related Services, Policy 8.01.03
Archived Back School, Policy 8.01.08
New Policies/Procedures:
Surgical Treatment of Varicosities, Policy 7.01.82
NEW POLICIES/REVISION -- Updated 12/16/02
12/16/02: Policies/Procedures Reviewed and/or Revised:
Durable Medical Equipment with attached table, Policy 1.01.01
Global Surgical Care Rules, Procedure 10.01.09A
New Policies/Procedures:
Transpupillary Thermotherapy, Policy 7.01.80
Photocoagulation of macular drusen, 7.01.81
NEW POLICIES/REVISION -- Updated 12/10/02
12/10/02: Policies/Procedures Reviewed and/or Revised:
Tumor Markers, Policy 11.01.01
Allergy Immunotherapy, Policy 2.01.17
Therapeutic Apheresis (Plasmapheresis), Policy 7.01.30
Intravenous (IV) Sedation, Procedure 9.01.03A
NEW POLICIES/REVISIONS -- Updated 11/25/02
11/25/02: Policies/Procedures Reviewed and/or Revised:
Emergency Services: Auto Codes, Procedure 10.01.11A
NEW POLICIES/REVISIONS -- Updated 11/19/02
11/19/02: Policies/Procedures Reviewed and/or Revised:
Anesthesia Services, Procedure 9.01.01A
NEW POLICIES/REVISIONS -- Updated 11/11/02
11/11/02: Policies/Procedures Reviewed and/or Revised:
Coverage for Hair Prostheses, Procedure 1.01.13A
Extracorporeal Magnetic Innervation (ExMI) for Urinary Incontinence, Policy 2.01.13
Cosmetic and Reconstructive Surgery, Policy 7.01.17
Archived Identification of Microorganisms Using Nucleic Acid Probes, Policy 11.01.23
New Policies/Procedures:
Interpositional Spacer forOsteoarthritis of the Knee Joint (e.g. UniSpacer™), Policy 7.01.78
Laryngeal Denervation and Reinnervation for Laryngeal Dystonia, Policy 7.01.79
NEW POLICIES/REVISIONS -- Updated 10/14/02
10/14/02: Policies/Procedures Reviewed and/or Revised:
Transcutaneous Electrical Nerve Stimulators (TENS), Policy 1.01.10
Archived Lyme Disease Vaccine (Lymerix®), Procedure 2.01.14A
Temporomandibular Joint (TMJ) Dysfunction, Policy 2.01.21
Ilizarov Bone Lengthening Procedure, Policy 7.01.11
NEW POLICIES/REVISIONS -- Updated 9/30/02
9/30/02: Policies/Procedures Reviewed and/or Revised:
High Frequency Chest Wall Oscillation Vest, Procedure 1.01.12A
Dynamic Orthotic Cranioplasty, Policy 1.03.02
Video Electroencephalographic (EEG) Monitoring, Policy 2.01.44
Low Osmolar Contrast Media, Policy 6.01.13
Surgical Correction of Refractive Errors, Procedure 7.01.20A
Obesity and Morbid Obesity, Policy 7.01.36
Lung Volume Reduction Surgery for Palliation of Severe Emphysema, Policy 7.01.62
Prophylactic Mastectomy, Policy 7.01.71
New Policies/Procedures:
Wireless Capsule Endoscopy (Enteral Camera), Policy 7.01.76
NEW POLICIES/REVISIONS -- Updated 9/20/02
9/20/02: Policies/Procedures Reviewed and/or Revised:
Adoptive Immunotherapy for Renal Cell Carcinoma, Policy 2.03.05
Keratoprosthesis, Policy 7.01.13
Archived Pallidotomy for Treatment of Parkinson's Disease, Policy 7.01.16
Autologous Chondrocyte Transplantation, Policy 7.01.48
Archived Plasma HIV RNA Quantification for HIV Infection, Policy 11.01.22
New Policies/Procedures:
Medical Record Documentation Standards, Procedure 10.01.13A
NEW POLICIES/REVISIONS -- Updated 9/06/02
9/06/02: Policies/Procedures Reviewed and/or Revised:
Fetal Mesencephalic Transplantation for the Treatment of Parkinson's Disease, Policy 7.01.10
Prolotherapy (Proliferative Therapy), Policy 7.01.67
Endovascular Coagulation Procedure (VNUS® Closure™ System), Policy 7.01.72
Solid Human Organ Transplants, Policy 7.03.01
Private Room, Procedure 10.01.07A
Archived Transjugular Intrahepatic Portosystemic Shunt (TIPS), Policy 7.01.09
Archived Sperm Evaluation, Hamster Penetration Test, Policy 11.01.13
NEW POLICIES/REVISIONS -- Updated 8/23/02
Neuropsychological Testing, Policy 2.01.28
Foot Care Services, Policy 7.01.18
Periurethral Injection of Collagen for the Treatment of Urinary Incontinence, Policy 7.01.19
Sacral Nerve Stimulation (Interstim™) for the Treatment of Urinary Continence Disorders, Policy 7.01.31
Archived Transmyocardial Laser Revascularization, Policy 7.01.54
Occupational Therapy, Policy 8.01.04
Speech Therapy, Policy 8.01.05
General Anesthesia for Dental Care, Procedure 9.01.07A
NEW POLICIES/REVISIONS -- Updated 8/09/02
Coverage for Hearing Aids (Maryland Mandate), Procedure 1.01.16A
Hyperthermia in the treatment of cancer, Policy 2.03.04
Photodynamic Therapy, Policy 2.03.07
Antineoplaston A Therapy, Policy 2.03.09
Intraoperative Radiation Therapy, Policy 6.01.17
Meniscal Allograft Transplantation, Policy 7.01.15
Recreational Activity as Physical Therapy (e.g., Golf, Hippotherapy), Policy 8.01.09
Habilitative Services, Procedure 8.01.11A
Archived Vitamin B12 Injection, Policy 2.01.12
Archived Intravascular Ultrasound (IVUS) Imaging, Policy 6.01.04
Archived Unna Boots, Policy 7.01.21
New Policies/procedures
Microvolt T-Wave Alternans, Policy 2.02.02
Thoracic electrical bioimpedance measurement , Policy 2.02.03
Staple Hemorrhoidectomy, Policy 7.01.77
NEW POLICIES/REVISIONS -- Updated 7/22/02
Acupuncture, procedure 2.01.48A
Vertebral Axial Decompression (VAX-D®), procedure 8.01.13A
Surgical Assistants, procedure 10.01.08A
NEW POLICIES/REVISIONS -- Updated 6/14/02
Ambulatory External Infusion Pumps, policy 1.01.09
Continuous Passive Motion (CPM) Device, policy 1.01.11
Orthotic Devices and Orthopedic Appliances, policy 1.03.01
Clinical Ecology, policy 2.01.01
Dynamic Posturography (e.g., Equitest), policy 2.01.02
Electrocorticography, policy 2.01.11
Allergy Immunotherapy, policy 2.01.17
Electrical Stimulation of the Ear, policy 2.01.19
Allergy Testing, policy 2.01.23
Sensory Stimulation for Coma Patients, policy 2.01.24
Surface Electromyography (EMG), policy 2.01.31
Electron Beam Computed Tomography (Ultrafast CT) (e.g., HeartScan®), policy 6.01.03
Transcranial Doppler Ultrasound, policy 6.01.07
Scintimammography (Miraluma™ Imaging), policy 6.01.25
Electrophrenic Pacemaker, policy 7.01.37
Care of the Normal Newborn, policy 10.01.06
Hypo-osmotic Swelling Test for Sperm Function, policy 11.01.09
Salivary Estriol for Assessment of Risk for Preterm Labor (SalEst®), policy 11.01.20
Archived Therapeutic Phlebotomy, policy 2.01.33
Archived Rotary Chair/Harmonic Acceleration Test, policy 2.01.37
Archived Audiant Bone Conductor, policy 7.01.03
New Policies/procedures
Orthotic Foot Inserts, policy 1.03.03
Professional Nutritional Counseling, procedure 2.01.50A
Anesthesia Services, procedure 9.01.01A
NEW POLICIES/REVISIONS -- Updated 4/05/02
4/05/02: Policies/Procedures Reviewed and /or Revised
Gait Analysis, policy 2.01.03
Rhinomanometry and Acoustic Rhinometry, policy 2.01.08
Medical Foods for Treatment of Inherited Metabolic Disorders, policy 2.01.26
Temperature Gradient Studies, policy 2.01.42
Hair Analysis, policy 2.01.43
Screening for Colorectal Cancer, policy 2.03.11
Ultrasound for the Evaluation of Paranasal Sinuses (e.g., Echosine), policy 6.01.14
Neutron Beam Radiotherapy, policy 6.01.18
Charged Particle (Proton or Helium Ion) Radiation Therapy, policy 6.01.19
Dynamic Cardiomyoplasty, policy 7.01.06
Cosmetic and Reconstructive Surgery, policy 7.01.17
Spinal Cord and Deep Brain Stimulation, policy 7.01.25
Physical Therapy, policy 8.01.01
Spinal Manipulation and Related Services, policy 8.01.03
Occupational Therapy, policy 8.01.04
Speech Therapy, policy 8.01.05
Archived Magnetic Resonance Angiography, policy 6.01.16
Archived Single Photon Emission Computed Tomography (SPECT) Scan, policy 6.01.23
Archived HPV Testing of Cervical Cytology, policy11.01.21
New Policies/Procedures:
Vagus Nerve Stimulation, policy 7.01.75
NEW POLICIES/REVISIONS -- Updated 3/05/02
3/05/02: Policies/Procedures Reviewed and/or Revised
Global Maternity Care, procedure 4.01.06A
Implantable Neuromuscular Stimulation, policy 7.01.47
Intravenous Patient-Controlled Analgesia (IV PCA), procedure 9.01.02A
Anesthesia Consultation, procedure 9.01.04A
New Policies/Procedures:
Excimer Laser Treatment for Psoriasis, policy 2.01.49
Global Surgical Care Rules, procedure 10.01.09A
NEW POLICIES/REVISIONS -- Updated 2/02/02
2/02/02: Policies/Procedures Reviewed and/or Revised
Ultrasound Accelerated Fracture Healing Device (e.g., Exogen®), policy 1.01.06
Home Apnea Monitors, policy 1.01.07
Prosthetics, policy 1.04.01
Thermography, policy 6.01.12
Magnetic Resonance Imaging (MRI) of the Breast, policy 6.01.22
New Policy:
Radiofrequency Ablation of Malignant Tumors of the Liver, policy 7.01.73
NEW POLICIES/REVISIONS -- Updated 1/18/02
1/18/02: Policies/Procedures Reviewed and/or Revised
Emergency Services: Auto Codes, procedure 10.01.11A
NEW POLICIES/REVISIONS -- Updated 1/11/02
1/11/02: Policies/Procedures Reviewed and/or Revised
Air fluidized beds, policy 1.01.02
Blood Glucose monitors, policy1.01.04
Transcutaneous Electrical Nerve Stimulator, procedure1.01.10A
Erectile Dysfunction, policy2.01.25
Diagnostic Eye Procedures, procedure2.01.38A
Acupuncture, procedure 2.01.48A
Enhanced Extracorporeal Counterpulsation (EECP), policy2.02.01
Mental Retardation, procedure 3.01.04A
Assisted Reproductive Technology, (ART )10/01/00*, procedure 4.02.01A
Artificial Insemination (AI)/Intrauterine Insemination (IUI), procedure 4.02.06A
Herniography, policy6.01.11
Low Osmolar Contrast Media, policy6.01.13
Image-Guided Surgery, procedure 6.01.21A
Disorders of the Prostate, policy7.01.04
Cochlear Implantation, policy 7.01.05
Vascular Angioscopy , policy7.01.08
Arthroscopic Thermocapsular Shrinkage for Joint Capsule, policy7.01.29
Insertable Cardiac Loop Event Monitor (eg Reveal), policy7.01.38
Habilitative Services, procedure8.01.11A
Intravenous Patient controlled Analgesia, procedure9.01.02A
Clinical Trials, procedure10.01.01A
Attendance at Delivery, procedure 10.01.02A
New Policies/Procedures
Electrical stimulation of the Pelvic Floor for Stress Urinary Incontinence,policy 2.01.47
12/13/01: Policies/Procedures Reviewed and/or Revised
Durable Medical Equipment with Attached Table, policy 1.01.01
Mental Retardation, procedure 2.01.46A
Mental Retardation, policy 3.01.04
Pervasive Developmental Disorders (e.g., Autism), policy 3.01.06
Pervasive Developmental Disorders (e.g., Autism), procedure 3.01.06A
Attention Deficit Disorder (ADD) with or without Hyperactivity, policy 3.01.09
Attention Deficit Disorder (ADD) with or without Hyperactivity, procedure 3.01.09A
Cosmetic and Reconstructive Surgery, policy 7.01.17
Oral Surgery, policy 7.01.22
Obesity and Morbid Obesity, policy 7.01.36
Cathepsin-D, policy 11.01.05
Infant Hearing Screening, procedure 2.01.46A
New Policies/procedures
Positron Emission Tomography (PET) for Diagnosis and Treatment of Multiple Sclerosis, policy 6.01.29
Positron Emission Tomography (PET) for diagnosis and treatment of Alzheimer's disease, policy 6.01.30
9/30/01: Policies/Procedures Reviewed and/or Revised
Hypnosis, Policy 2.01.06
Screening for Colorectal Cancer, Policy 2.03.11
Epoetin Alfa (e.g., Epogen®, Procrit®), Policy 5.01.04
Botulinum Toxin (e.g., Botox®, Oculinum™), Policy 5.01.05
Ultrasound (Echography) of the Spinal Canal and Contents, Policy 6.01.24
Cochlear Implantation, Procedure 7.01.05A
Cerebellar Stimulation, Policy 7.01.27
Percutaneous Vertebroplasty, Policy 7.01.32
Sclerotherapy for External Varicosities, Policy 7.01.55
Sclerotherapy for External Varicosities, Procedure 7.01.55A
New Policies/Procedures:
Scanning the Lungs with Electron Beam Computed Tomography (e.g.,Virtual Lung Scan), Policy 6.01.27
Scanning the Colon with Electron Beam Computed Tomography (e.g.,Virtual Colonoscopy), Policy 6.01.28
Spinal Manipulation and Related Services, Policy 8.01.03
Spinal Manipulation and Related Services, Policy 8.01.03A
9/5/01: Policies reviewed without changes
Carbogen Therapy for Sudden Hearing Loss, Policy 2.01.29
Interleukin-2 (IL-2)/Aldesleukin (e.g., Proleukin), Policy 5.01.11
8/31/01: Policies/Procedures Archived:
Intravenous Histamine Therapy, Policy 2.01.05
Esophageal Monitoring, Policy 2.01.20
Osteochondral Autograft Transfer System (OATS) Procedure, Policy 7.01.34
Fetal Fibronectin Enzyme Immunoassay, Policy 11.01.06
8/11/01: Policies/Procedures Reviewed and/or Revised:
Growth Factors for Wound Healing, Policy 2.01.16
Colony Stimulating Factors, Policy 5.01.03
Low Osmolar Contrast Media, Policy 6.01.13
Obesity and Morbid Obesity, Procedure 7.01.36A
Genetic Testing for Medullary Carcinoma of the Thyroid, Policy 11.01.07
7/27/01: Policies Reviewed and/or Revised:
H-wave Electrical Stimulation Devices (e.g., VST-100® Myodynamic Prosthesis), Policy 1.01.05
Continuous Glucose Monitoring System, Policy 2.01.45
Salivary Melatonin Profile, Policy 11.01.08
7/20/01: Policy Revised:
Selective Posterior Rhizotomy for the Spasticity of Cerebral Palsy, Policy 7.01.28
7/12/01: Policy Reviewed, no changes:
Orthoptics/Pleoptics (Vision Therapy), Policy 2.01.15
Policy Archived:
Stereotactic Electroencephalography, Policy 7.01.39
7/11/01: Policy reviewed without changes:
Multifetal Pregnancy Reduction, Policy 4.02.03A
7/1/01: New Medical Policies and Procedures:
Genetic Testing and Surveillance of Colon Cancer, Policy 2.03.10
Screening for Colorectal Cancer, Policy 2.03.11
Diagnosis: Family History of, Procedure 10.01.10A
Policies Reviewed and/or Revised:
Sleep Disorders, Policy 2.01.18
Biofeedback, 2.01.35
High-Dose Chemotherapy/Radiation Therapy with Autologous Bone Marrow/Peripheral Stem Cell Support, Policy 7.03.02
High-Dose Chemotherapy/Radiation Therapy with Autologous Bone Marrow/Peripheral Stem Cell Support, Procedure 7.03.02A
Allogeneic Bone Marrow Transplantation for Malignant and Non-Malignant Conditions, Policy 7.03.03
Allogeneic Bone Marrow Transplantation for Malignant and Non-Malignant Conditions, Procedure 7.03.03A
6/23/01: Policies Reviewed and Revised:
Audiometric Testing, Policy 2.01.30
Isolated Limb Perfusion, Policy 2.03.06
Human Growth Hormone (HGH) Therapy for Children and Adults, Policy 5.01.09
New Policy:
Scanning with Electron Beam Computed Tomography (e.g., Virtual Physical™), Policy 6.01.26
6/21/01: Policies Reviewed and Revised:
Cosmetic and Reconstructive Surgery, Policy 7.01.17
Endovascular Coagulation Procedure (VNUS® Closure™ System), Policy 7.01.72
6/1/01: Policies Reviewed and/or Revised
Hyperbaric Oxygen Therapy (HBO2), Policy 2.01.04
Brachytherapy for Malignant Tumors, Policy 6.01.20, Previously titled Interstitial Brachytherapy
Magnetic Resonance Imaging (MRI) of the Breast, Policy 6.01.22
Electrical Bone Growth Stimulation, Policy 7.01.07
Percutaneous Vertebroplasty, Policy 7.01.32
Implantable Neuromuscular Stimulation, Policy 7.01.47
Placental and Umbilical Cord Blood as a Source of Stem Cells, Policy 7.03.04
Donor Leukocyte Infusion, Policy 7.03.05
Ambulance Services, Policy 10.01.05
Ambulance Services, Procedure 10.01.05A
Genetic Testing for Inherited BRCA1 or BRCA2 Mutations, Policy 11.01.02
Anti-Gliadin and Anti-Endomysial Antibodies, Policy 11.01.03
Paternal or Fetal Antigen Immunotherapy for Recurrent Fetal Loss, Policy 11.01.14
Ericsson Sex Pre-Selection Technique with Artificial Insemination, Policy 11.01.15
New Medical Policy:
Peripheral Vascular Disease Rehabilitation, Policy 8.01.12
Policies reviewed without changes:
Pervasive Developmental Disorders (e.g., Autism), Policy 3.01.06
Attention Deficit Disorder (ADD) with or without Hyperactivity, Policy 3.01.09
Clinical Trials, 10.01.01A
5/29/01: Policy Reviewed and Revised
Quantitative Electroencephalogram (Topographic Brain Mapping), Policy 2.01.10
5/24/01: Policy Archived:
Lactoferrin Tear Microassay, Policy 11.01.18
Procedure Revised:
Standby Services, Procedure 10.01.04A
New Procedure:
Wheelchairs and Manual or Power Operated Vehicles, Procedure 1.01.14A
5/16/01: Policy/Procedure Reviewed without changes:
Tilt Table, Policy 2.01.09
5/9/01: Policy/Procedure Reviewed without changes:
Hypnosis, Policy 2.01.06
Hypnosis, Procedure 2.01.06A
5/5/01: Policies/Procedures Reviewed and/or Revised:
Elemental Nutrition for Treatment of Malabsorption Disorders, Policy 1.02.02
Elemental Nutrition for Treatment of Malabsorption Disorders, Procedure 1.02.02A
Photodynamic Therapy, Policy 2.03.07
Obesity and Morbid Obesity, Policy 7.01.36
New Policies/Operating Procedures:
Physical Therapy, Policy 8.01.01
Physical Therapy, Policy 8.01.01A
Occupational Therapy, Policy 8.01.04
Occupational Therapy, Procedure 8.01.04A
4/24/01: Procedure Revised:
Mifepristone (e.g. Mifeprex™, RU 486), Procedure 5.01.14A
4/20/01: Policy Reviewed without changes:
Electron Beam Computed Tomography (Ultrafast CT) (e.g., HeartScan®),
Policy 6.01.03
Intradiscal Electrothermal Therapy, Policy 7.01.49
4/18/01: Procedures Revised:
Assisted Reproductive Technology (ART) Procedures - 10/01/00*, Procedure 4.02.01A
Assisted Reproductive Technology (ART) Procedures - Prior to 10/01/00*, Procedure 4.02.01
4/5/01: New Policy
Care of the Normal Newborn, Policy 10.01.06
3/25/01: Policies Reviewed and/or Revised
Allergy Testing, Policy 2.01.23
Stereotactic Radiosurgery, Policy 6.01.10
Audiant Bone Conductor, Policy 7.01.03
Tumor Markers, Policy 11.01.01
3/2/01: Reviewed and/or Revised Policies
Introduction: Definitions and Interpretive Guidelines
Positron Emission Tomography (PET), Policy 6.01.06
Low Osmolar Contrast Media, Policy 6.01.13
Archived Policies and Procedures
Bone Density Studies, Policy 6.01.01
Bone Density Studies, Procedure 6.01.01
2/24/01: Policies Reviewed without changes:
Placental and Umbilical Cord Blood as a Source of Stem Cells, Procedure 7.03.04A
Work Hardening Programs, Policy 8.01.07
2/23/01: Policy Archived
Rabies Treatment, Policy 2.01.22
2/21/01: Procedure Reviewed and Revised:
Global Maternity Care, Procedure 4.01.06A
1/17/01: New Procedure:
Surgical Assistants, Procedure 10.01.08A
1/12/01: Policies Revised:
Phototherapy, Policy 2.01.07
Uterine Artery Embolization for Fibroid Tumors (Leiomyomata), Policy 4.01.08
Off-Label and Orphan Drug Use, Policy 5.01.01
Transmyocardial Laser Revascularization, Policy 7.01.54
New Operating Procedures
Mifepristone (e.g. Mifeprex™, RU 486), Procedure 5.01.14A
Intravenous (IV) Sedation, Procedure 9.01.03A
1/10/01: Policies Reviewed/Revised
Durable Medical Equipment with Attached Table, Policy 1.01.01
Diagnostic Eye Procedures, Procedure 2.01.38A
Eyeglasses and Contact Lenses for Medical or Post-Operative Conditions, Procedure 2.01.39A Refraction, Procedure 2.01.40A
Percutaneous Electrical Nerve Stimulation (PENS), Policy 7.01.23
Cerebellar Stimulation/Pacemaker, Policy 7.01.23
Selective Posterior Rhizotomy for the Spasticity of Cerebral Palsy, Policy 7.01.28
Laparoscopic Intestinal Surgery, Policy 7.01.61
Tumor Markers, Policy 11.01.01
In Vitro Chemotherapeutic Drug Assays (e.g., LifeTrac™, Oncotech EDR®), Policy 11.01.19
New Policies/Procedures:
Intravenous Patient-Controlled Analgesia (IV PCA), Procedure 9.01.02A
Epidural Analgesia, Post-Operative or Non-Surgical, Procedure 9.01.05A
Care of the Normal Newborn, 10.01.06A
12/16/00: Policies Reviewed/Revised
Erectile Dysfunction, Policy 2.01.25
Photodynamic Therapy, Policy 2.03.07
Interleukin-2 (IL-2)/Aldesleukin (e.g., Proleukin), Policy 5.01.11
Positron Emission Tomography (PET), Policy 6.01.16
Interstitial Brachytherapy, Policy 6.01.20
Diagnostic Testing for Alzheimer's Disease (AD), Policy 11.01.04
12/15/00 New Policy
Continuous Glucose Monitoring System, Policy 2.01.45
Policies Archived*:
Transexual Surgery, Policy 7.01.70
12/4/00: Policies Archived*:
Adrenal to Brain Transplant, Policy 7.01.43
Signal-Averaged Electrocardiography (SAECG), Policy 2.02.04
*Archived policies appear in the "99." section of the Medical Policy Reference Manual.
Refer to the History section of archived policies for claims processing instructions.
11/25/00: Reviewed and/or Revised Policies:
Hyperbaric Oxygen Therapy (HBO2), Policy 2.01.04
Disorders of the Prostate, Policy 7.01.04
Arthroscopic Thermocapsular Shrinkage for Joint Capsule, Policy 7.01.29
11/23/00: New Procedure:
High Frequency Chest Wall Oscillation Vest, Procedure 1.01.12A
11/17/00: Policies Reviewed and/or Revised
Vitamin B12 Injection, Policy 2.01.12
Allergy Immunotherapy, Policy 2.01.17
Chemoembolization, Policy 2.03.03
Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging), Policy 6.01.05
New Medical Policy:
Plasma HIV RNA Quantification for HIV Infection, Policy 11.01.22 (replaces 11.01.17)
Archived Policy:
HIV Viral Load Testing, Policy 11.01.17 (replaced by 11.01.22)
11/16/00: Archived Policy:
Extracorporeal Shock Wave Lithotripsy, Policy 7.01.35
Introduction Revised:
Dates Referenced in Medical Policies and Operating Procedures
Definitions and Interpretive Guidelines (changed from Definitions and Terms)
11/15/00: Policy Reviewed (without changes):
Back School, Policy 8.01.08
10/30/00: Policy Revised:
Dynamic Orthotic Cranioplasty, Policy 1.03.02
10/26/00: Policy Archived:
IGF Binding Protiens, Policy 11.01.16
10/23/00: Archived Procedure:
Ultrasound in Pregnancy, Procedure 4.01.07A
10/18/00: Policies Reviewed and/or Revised:
Introduction: Maintenance
Introduction: Organization and Format
Extracorporeal Magnetic Innervation (ExMI) for Urinary Incontinence, Policy 2.01.13
Policies Archived:
Amniocentesis and Chorionic Villus Sampling (CVS), Policy 4.01.02
Ultrasound in Pregnancy, Policy 4.01.07
10/13/00: Policy Revised
Uterine Artery Embolization for Fibroid Tumors (Leiomyomata), Policy 4.01.08
10/6/00: New Policy:
Identification of Microorganisms Using Nucleic Acid Probes, Policy 11.01.23
New Operating Procedure:
Private Room, Procedure 10.01.07A
Revised Operating Procedure:
Preventive Services, Procedure 10.01.03A
10/1/00: New Operating Procedures:
Habilitative Services, Procedure 8.01.11A
Coverage for Hair Prostheses, Procedure 1.01.13A
Revised Operating Procedure:
Assisted Reproductive Technology (ART) Procedure, Procedure 4.02.01A
9/29/00 New Medical Policies:
Video Electroencephalographic (EEG) Monitoring, Policy 2.01.44
Prophylactic Mastectomy, Policy 7.01.71
HPV Testing of Cervical Cytology, Policy 11.01.21
9/16/00 Procedure Reviewed and Revised:
Lyme Disease Vaccine (Lymerix®), Procedure 2.01.14A
Surgical Correction of Refractive Errors, Procedure 7.01.20A
9/8/00: Policies Archived:
Implantable Infusion Pump, Policy 7.01.24
Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae, Policy 7.01.26
8/28/00: Policies Reviewed/Revised:
Temporomandibular Joint (TMJ) Dysfunction, Policy 2.01.21
Magnetic Resonance Imaging (MRI) of the Breast, Policy 6.01.22
High-Dose Chemotherapy/Radiation Therapy with Autologous Bone Marrow/Peripheral Stem Cell Support, Policy 7.03.02
New Operating Procedure:
Temporomandibular Joint (TMJ) Dysfunction, Procedure 2.01.21A
8/20/00: "99. Archived" Section added to database
Previously archived policies added* :
Hemoperfusion, Policy 2.01.32
Intracardiac Electrophysiologic Studies, Policy 2.02.05
Cervicography, Policy 4.01.04
Avonex/Betaseron/Copaxone for the Treatment of Multiple Sclerosis, Policy 5.01.06
Magnetic Resonance Guidance for Surgical Procedures, Policy 6.01.21
Catheter Ablation for Cardiac Arrhythmias, Policy 7.01.01
Angelchik™ Anti-Reflux Prosthesis, Policy 7.01.02
Transfusion Therapy for Hemolytic Disease of the Fetus and the Newborn, Policy 7.01.12
Maze Procedure, Policy 7.01.14
Serum Toxicity Test, Policy 11.01.10
Sperm Antibodies, Policy 11.01.11
Sperm-Cervical Mucus Penetration (Huhner Test), Policy 11.01.12
*NOTE: See Introduction, under "Maintenance" for definition of archived policies .
Policy Revised:
Botulinum Toxin (e.g., Botox®, Oculinum™), Policy 5.01.05
Policy Reviewed without changes:
Unna Boots, Policy 7.01.21
8/17/00: Operating Procedure Revised:
Neuropsychological Testing, Procedure 2.01.28A
8/12/00: Policies Reviewed/Revised:
Transjugular Intrahepatic Portosystemic Shunt (TIPS), Policy 7.01.09
Prolotherapy (Proliferative Therapy), Policy 7.01.67
Sperm Evaluation, Hamster Penetration Test, Policy 11.01.13
8/9/00: Policy Reviewed Without Changes:
Lung Volume Reduction Surgery, Policy 7.01.62
8/2/00: New Medical Policy
Scintimammography (Miraluma™ Imaging), Policy 6.01.25
7/30/00: Policies Reviewed/Revised
Photodynamic Therapy, Policy 2.03.07
Cochlear Implantation, Policy 7.01.05
Fetal Mesencephalic Transplantation for the Treatment of Parkinson’s Disease, Policy 7.01.10
Ilizarov Bone Lengthening Procedure, Policy 7.01.11
Keratoprosthesis, Policy 7.01.13
Pallidotomy for Treatment of Parkinson’s Disease, Policy 7.01.16
Autologous Chondrocyte Transplantation, Policy 7.01.48
7/29/00: Procedure revised:
Solid Human Organ Transplants, Procedure 7.03.01A
7/24/00: Policy Archived
Serum Toxicity Test, Policy 11.01.10
7/13/00: Policies Archived:
Sperm Antibodies, Policy 11.01.11
Sperm-Cervical Mucus Penetration (Huhner Test), Policy 11.01.12
7/1/00: Procedures Revised:
General Anesthesia for Dental Care, Procedure 9.01.07A
Obesity and Morbid Obesity, Procedure 7.01.36A
6/30/00: Reviewed and/or Revised Medical Policies/Operating Procedures:
Introduction: Purpose
Neuropsychological Testing, Policy 2.01.28
Neuropsychological Testing, Procedure 2.01.28A
Mental Retardation, Policy 3.01.04
Mental Retardation, Procedure 3.01.04A
Ultrasound (Echography) of the Spinal Canal and Contents, Policy 6.01.24
Foot Care Services, Policy 7.01.18
Periurethral Injection of Collagen for the Treatment of Urinary Incontinence, Policy 7.01.19
Therapeutic Apheresis (Plasmapheresis), Policy 7.01.30
Sacral Nerve Stimulation (Interstim™) for Treatment of Urinary Continence Disorders, Policy 7.01.31
6/29/00: Policies Archived*:
Transfusion Therapy for Hemolytic Disease of the Fetus and the Newborn, Policy 7.01.12
Maze Procedure, Policy 7.01.14
6/11/00: Reviewed/Revised Medical Policies:
Transcutaneous Electrical Nerve Stimulators (TENS), Policy 1.01.10
Botulinum Toxin (e.g., Botox®, Oculinum™), Policy 5.01.05
Intravascular Ultrasound (IVUS) Imaging, Policy 6.01.04
Interstitial Brachytherapy, Policy 6.01.20
Meniscal Allograft Transplantation, Policy 7.01.15
Percutaneous Electrical Nerve Stimulation (PENS), Policy 7.01.23
Percutaneous Vertebroplasty, Policy 7.01.32
6/6/00: Revised Policy
Obesity and Morbid Obesity, Policy 7.01.36
6/2/00: New Policy
Uterine Artery Embolization for Fibroid Tumors (Leiomyomata), Policy 4.01.08
6/1/00: Reviewed and /or Revised Policies and Procedures
Antineoplaston A Therapy, Policy 2.03.09
Ultrasound in Pregnancy, Policy 4.01.07
Ultrasound in Pregnancy, Procedure 4.01.07A
Colony Stimulating Factors, Policy 5.01.03
Spinal Cord and Deep Brain Stimulation, Policy 7.01.25
Recreational Activity as Physical Therapy (e.g., Golf, Hippotherapy), Policy 8.01.09
5/31/00: Policy Archived*:
Angelchik™ Anti-Reflux Prosthesis, Policy 7.01.02
5/18/00: New Procedure:
Cochlear Implantation, Procedure 7.01.05A
Revised Procedure:
Diagnostic Eye Procedures, Procedure 2.01.38A
5/11/00: Policy Archived*:
Catheter Ablation for Cardiac Arrhythmias, Policy 7.01.01
*NOTE: See Introduction, under "Maintenance" for definition of archived policies.
The archived database should be available on Lotus Notes® June-July 2000.
5/10/00: Policies Revised and/or Reviewed:
Enhanced Extracorporeal Counterpulsation (EECP), Policy
Positron Emission Tomography (PET), Policy 6.01.06
Transmyocardial Laser Revascularization, Policy 7.01.54
5/6/00: Policies/Procedures reviewed and revised:
Medical Policy Reference Manual Introduction
Biofeedback, Policy 2.01.35
Rotary Chair/Harmonic Acceleration Test, Policy 2.01.37
Vertebral Axial Decompression (VAX-D), Policy 2.01.41
Signal-Averaged Electrocardiography (SAECG), Policy 2.02.04
Hyperthermia, Policy 2.03.04
Charged Particle (Proton or Helium Ion) Radiation Therapy, Policy 6.01.19
Disorders of the Prostate, Policy 7.01.04
5/5/00: New Medical Policies:
Intradiscal Electrothermal Therapy, Policy 7.01.49
Endovascular Coagulation Procedure (VNUS® Closure™ System), Policy 7.03.06
5/2/00: Policy Archived:
Avonex/Betaseron/Copaxone for the Treatment of Multiple Sclerosis, Policy 5.01.06
4/26/00: Policies/Procedures reviewed or revised:
Durable Medical Equipment with Attached Table, Policy 1.01.01
Ambulatory External Infusion Pumps, Policy 1.01.09
Continuous Passive Motion (CPM) Device, Policy 1.01.11
Orthotic Devices, Procedure 1.03.01A
Prosthetics, Procedure 1.04.01A
Hyperbaric Oxygen Therapy, Policy 2.01.04
Electrocorticography, Policy 2.01.11
Sensory Stimulation for Coma Patients, Policy 2.01.24
Transcranial Doppler Ultrasound, Policy 6.01.07
Electrical Bone Growth Stimulation, Policy 7.01.07
Solid Human Organ Transplants, Policy 7.03.01
Solid Human Organ Transplants, Procedure 7.03.01A
Ambulance Services, Procedure 10.01.05A
Salivary Estriol for Assessment of Risk for Preterm Labor (SalEst),
Policy 11.01.20
4/26/00: New Medical Policy added:
Hair Analysis, Policy 2.01.43
3/27/00: Policies Archived*:
Intracardiac Electrophysiologic Studies, Policy 2.02.05
Hemoperfusion, Policy 2.01.32
*NOTE: See Introduction, under "Maintenance" for definition of archived policies. Archived policies will be available online by May 2000.
3/22/00: New Medical Policy added:
Temperature Gradient Studies, Policy 2.01.42
3/18/00: Policies reviewed and revised:
Clinical Ecology, Policy 2.01.01
Dynamic Posturography (e.g., Equitest), Policy 2.01.02
Electrical Stimulation of the Ear, Policy 2.01.19
Policy revised:
Sleep Disorders, Policy 2.01.18
Ambulance Services, Policy 10.01.05
3/08/00: Policy reviewed without changes:
Audiometric Testing, Policy 2.01.30
3/04/00: Policies revised:
Allergy Immunotherapy, Policy 2.01.17
Allergy Testing, Policy 2.01.23
Policies revised and/or reviewed:
Automated Ambulatory Blood Pressure Monitor, Policy 1.01.03
Ultrasound Accelerated Fracture Healing Device (e.g., Exogen®), Policy 1.01.06
Tumor Markers, Policy 11.01.01
Hypo-osmotic Swelling Test for Sperm Function, Policy 11.01.09
2/23/00: Policy reviewed without changes:
Therapeutic Phlebotomy, Policy 2.01.33
2/16/00: New operating procedure added:
Image Guided Surgery, Procedure 6.01.21A (REPLACES Magnetic Resonance Guided Surgical Procedures, Policy 6.01.21)
2/12/00: Policies revised:
Positron Emission Tomography (PET), Policy 6.01.06
Stereotactic Radiosurgery, Policy 6.01.10
Spinal Cord and Deep Brain Stimulation, Policy 7.01.25
1/29/00: Policies/procedures revised and/or reviewed:
Gait Analysis, Policy 2.01.03
Medical Foods for Inherited Metabolic Disorders, Policy 2.01.26
Medical Foods for Inherited Metabolic Disorders, Procedure 2.01.26A
Surface Electromyography (EMG), Policy 2.01.31
Epoetin Alfa (Epogen® , Procrit® ), Policy 5.01.04
Botulinum Toxin (e.g., Botox® , Oculinum™ ), Policy 5.01.05
Human Growth Hormone (HGH) Therapy for Children and Adults, Policy 5.01.09
Interleukin-2 (IL-2)/ Aldesleukin (e.g., Proleukin®), Policy 5.01.11
Intravenous Immune Globulin (IVIG) Therapy, Policy 5.01.13
Neutron Beam Radiotherapy, Policy 6.01.18
Charged Particle (Proton or Helium Ion) Radiation Therapy, Policy 6.01.19
Audiant Bone Conductor, Policy 7.01.03
Electrophrenic Pacemaker, Policy 7.01.37
Cardiac Rehabilitation, Policy 8.01.02
Cardiac Rehabilitation, Procedure 8.01.02A
1/14/00 New Procedure added:
Cervicography (4.01.04A) (Procedure replaces Cervicography, Policy 4.01.04)
Deleted Introductions from the Database:
1.01 Durable Medical Equipment Introduction
1.02 Medical Supplies Introduction
1.03 Orthotic Devices Introduction
1.04 Prosthetic Appliances Introduction
2.01 Medicine Introduction
2.02 Cardiology Introduction
2.03 Oncology Introduction
3.01 Mental Health Introduction
4.01 OB/GYN Introduction
4.02 Reproduction Introduction
5.01 Prescription Drug Introduction
6.01 Radiology/Imaging Introduction
7.01 Surgery Introduction
7.03 Transplant Introduction
8.01 Rehabilitation Therapy Introduction
9.01 Anesthesia Introduction
10.01 Administrative Policies Introduction
11.01 Laboratory/Pathology Introduction
12/21/99 Year 2000 CPT codes added to the following policies:
Photodynamic Therapy, Policy 2.03.07
Charged Particle (proton or helium ion), Policy 6.01.19
Therapeutic Apheresis, Policy 7.01.30
Insertable Cardiac Loop Event Monitor, Policy 7.01.38
Transmyocardial Revascularization, Policy 7.01.54
Laproscopic Intestinal Surgery, Policy 7.01.61
12/16/99 Policies/procedures revised and/or reviewed:
Home Apnea Monitors, Policy 1.01.07
Home Apnea Monitors, Procedure 1.01.07A
Off-Label and Orphan Drug Use, Policy 5.01.01
Thermography, Policy 6.01.12
Ultrasound for the Evaluation of Paranasal Sinuses (e.g., Echosine), Policy 6.01.14
Magnetic Resonance Angiography, Policy 6.01.06
Single Photon Emission Computed Tomography (SPECT) Scan, Policy 6.01.23
Dynamic Cardiomyoplasty, Policy 7.01.06
12/1/99 Procedures reviewed and revised:
Assisted Reproductive Technology (ART) Procedures, Procedure 4.02.01A
Artificial Insemination (AI)/Intrauterine Insemination (IUI), Procedure 4.02.06A
New Procedures:
Pulmonary Rehabilitation, Procedure 8.01.10A
11/22/99 Policies reviewed:
Air Fluidized Beds, Policy 1.01.02
Blood Glucose Monitors (Glucometers), Policy 1.01.04
11/19/99 Policies/procedures revised and/or reviewed:
Transcutaneous Electrical Nerve Stimulator (TENS) (e.g., AccuTron, Alpha-Stim, MicroStim),
Policy 1.01.01 and Procedure 1.01.01(A)
Sleep Disorders, Policy 2.01.18
Pervasive Developmental Disorders (e.g., Autism), Policy 3.01.06
Attention Deficit Disorder (ADD) with or without Hyperactivity, Policy 3.01.09
Herniography, Policy 6.01.11
Low Osmolar Contrast Media, Policy 6.01.13
Intraoperative Radiation Therapy, Policy 6.01.17
Obesity and Morbid Obesity, Policy 7.01.36
New policies/procedures added:
Enhanced Extracorporeal Counterpulsation (EECP), Policy 2.02.01
Pervasive Developmental Disorders (e.g., Autism), Procedure 3.01.06 (A)
Attention Deficit Disorder (ADD) with or without Hyperactivity, Procedure 3.01.09 (A)
Arthroscopic Thermocapsular Shrinkage of the Shoulder Joint Capsule for Recurrent
Dislocation, Policy 7.01.29
Percutaneous Vertebroplasty, Policy 7.01.32
Obesity and Morbid Obesity, Procedure 7.01.36 (A)
Insertable Cardiac Loop Event Monitor (e.g., Reveal®), Policy 7.01.38
Preventive Services, Procedure 10.01.03A
11/2/99 Policies/procedures revised:
Amniocentesis and Chorionic Villus Sampling, Policy 4.01.02 (added Place of Service "Office" and "Inpatient")
9/24/99: Policies/procedures revised:
Chelation Therapy, Policy 2.01.27
Chemoembolization, Policy 2.03.03
Adoptive Immunotherapy, Policy 2.03.05
Isolated Limb Perfusion, Policy 2.03.06
Amniocentesis and Chorionic Villus Sampling (CVS), Policy 4.01.02
Electron Beam Computed Tomography (Ultrafast CT) (e.g., HeartScan®), Policy 6.01.03
Disorders of the Prostate, Policy 7.01.04
Ventricular Assist Devices as a Bridge to Heart Transplantation, Policy 7.03.11
9/15/99: New policies/procedures added:
Surgical Correction of Refractive Errors, Procedure 7.01.20A
Oral Surgery, Procedure 7.01.22A
Policies/procedures revised:
Orthotic Devices, Procedure 1.03.01A
Vitamin B12 Injection, Policy 2.01.12
Growth Factors for Wound Healing, Policy 2.01.16
Esophageal pH Monitoring, Policy 2.01.20
Rabies Treatment, Policy 2.01.22
Allergy Testing, Policy 2.01.23
Erectile Dysfunction, Policy 2.01.25
Carbogen Therapy for Sudden Hearing Loss, Policy 2.01.29
Oral Surgery, Policy 7.01.22
7/28/99: New policies/procedures added:
Hypnosis, Procedure 2.01.06A
Sclerotherapy for External Varicosities, Policy 7.01.55 and Procedure 7.01.55A
Policies/procedures revised:
Gait Analysis, Policy 2.01.03
Hypnosis, Policy 2.01.06
Phototherapy, Policy 2.01.07
Tilt Table, Policy 2.01.09
Foot Care Services, Policy 7.01.18
7/16/99: New policies/procedures added:
Placental and Umbilical Cord Blood as a Source of Stem Cells, Procedure 7.03.04A
Policies/procedures revised:
Sacral Nerve Stimulation for Treatment of Urge Incontinence (Interstim™), Policy 7.01.31
Placental and Umbilical Cord Blood as a Source of Stem Cells, Policy 7.03.04
7/1/99: New policies/procedures added:
Home Apnea Monitors, Procedure 1.01.07A
Neuropsychological Testing, Procedure 2.01.28A
Policies/procedures revised:
Home Apnea Monitors, Policy 1.01.07
Neuropsychological Testing, Policy 2.01.28
Positron Emission Tomography (PET), Policy 6.01.06
Cochlear Implantation, Policy 7.01.05
Clinical Trials, Policy 10.01.01A
Genetic Testing for Inherited BRCA1 or BRCA2 Mutations, Policy 11.01.02
6/19/99: New policies/procedures added:
Solid Human Organ Transplants, Procedure 7.03.01A
Policies/procedures revised:
Surface Electromyography (EMG), Policy 2.01.31
Herniography, Policy 6.01.11
Unna Boots, Policy 7.01.21
Spinal Cord and Deep Brain Stimulation, Policy 7.01.25
Implantable Neuromuscular Stimulation, Policy 7.01.47
Solid Human Organ Transplants, Policy 7.03.01
Ambulance Services, Policy 10.01.05 and Procedure 10.01.05A
6/3/99: New policies/procedures added:
Ultrasound in Pregnancy, Policy 4.01.07
Policies/procedures revised:
Ultrasound Accelerated Fracture Healing Device (e.g., Exogen®), Policy 1.01.06
Erectile Dysfunction, Policy 2.01.25
Ultrasound in Pregnancy, Procedure 4.01.07A
Botulinum Toxin (e.g., Botox®, Oculinum™), Policy 5.01.05
Cochlear Implantation, Policy 7.01.05
In Vitro Chemotherapeutic Drug Assays (e.g., LifeTrac™, Oncotech EDR®), Policy 11.01.19
5/21/99: New policies/procedures added:
Lyme Disease Vaccine (Lymerix®), Procedure 2.01.14A
Attendance at Delivery, Procedure 10.01.02A
Salivary Estriol for Assessment of Risk for Preterm Labor (SalEst®), Policy 11.01.20
Procedures revised:
Orthotic Devices, Procedure 1.03.01A
Prosthetics, Procedure 1.04.01A
4/21/99: Policies revised:
Durable Medical Equipment with Attached Table, Policy 1.01.01
Cosmetic and Reconstructive Surgery, Policy 7.01.17
Standby Services, Procedure 10.01.04A
3/31/99: New policies/procedures added:
Multifetal Pregnancy Reduction, Procedure 4.02.03A
Osteochondral Autograft Transfer System (OATS) Procedure, Policy 7.01.34
Recreational Activity as Physical Therapy (e.g., Golf, Hippotherapy), Policy 8.01.09
Genetic Testing for Inherited BRCA1 or BRCA2 Mutations, Policy 11.01.02
Policies/procedures revised:
Intravenous Histamine Therapy, Policy 2.01.05
Sleep Disorders, Policy 2.01.18
Erectile Dysfunction, Policy 2.01.25
Medical Foods for Treatment of Inherited Metabolic Disorders, Policy 2.01.26
Audiometric Testing, Policy 2.01.30
Percutaneous Electrical Neuromuscular Stimulation (PENS), Policy 7.01.23
Allogeneic Bone Marrow Transplantation, Procedure 7.03.03A
Cardiac Rehabilitation, Policy 8.01.02
Fetal Fibronectin Enzyme Immunoassay, Policy 11.01.06
2/1/99: Introduction finalized and approved.
1/26/99: New policies added:
Paternal or Fetal Antigen Immunotherapy for Recurrent Fetal Loss, Policy 11.01.14
Ericsson Sex Pre-Selection Technique with Artificial Insemination, Policy 11.01.15
1/12/99: Introduction revised.
12/21/98: Introduction section added. |