Clinical Policies

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A
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C
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E
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M
N
O
P
R
S
T
V
W
X

A
- Acoustic cardiography/heart sound recording
- Actigraphy
- Acupuncture
- Air ambulance transport
- Altered auditory feedback devices for speech dysfluency (stuttering)
- Ambulatory blood pressure monitoring
- Ambulatory continuous peripheral nerve block for chronic pain
- Apnea monitors for infants-in home use
- Aquatic therapy
- Art therapy
- Athletic pubalgia (sports hernia) surgery
- Auricular stimulation for abdominal pain from irritable bowel syndrome
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B
- Balloon dilation of the Eustachian tube
- Behavioral health weight management interventions for children with increased body mass index screenings
- Bioimpedance devices for detecting lymphedema
- Blue Native polyacrylamide gel electrophoresis for mitochondrial myopathies
- Bone graft substitutes
- Bone marrow transplant for children with hyper IgM disorder
- Botulinum toxin for constipation
- Brachytherapy for cancers other than prostate
- Breast pumps
- Bronchial thermoplasty for severe asthma
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C
- Cardiac contractility modulation
- Cecostomy for fecal incontinence
- Cervical cancer and human papillomavirus screening
- Cervical traction devices for neck pain for home use
- Chronic inflammatory response syndrome
- Computer-aided detection and diagnosis for chest imaging
- Computerized gait analysis
- Core decompression for avascular necrosis of the hip
- Corneal cross-linking
- Coronary intravascular lithotripsy
- Cryopreservation of reproductive tissue, gametes, and embryos
- Customized lymphedema garments
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D
- Dermabrasion and chemical peel
- Digestive enzyme cartridge
- Disposable insulin delivery devices
- Donor human milk
- Drug-eluting sinus implants
- Dynamic movement orthoses (suit therapy)
- Dynamic splinting
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E
- Electrical muscle stimulation
- Embrace 2 watch for seizure detection.
- EndeavorRx video for ADHD
- Endovenous stents
- Epidermal nerve fiber density testing
- Equine-assisted therapy
- Excimer laser for vitiligo
- External counterpulsation therapy
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F
- Face transplantation
- Fetal surgeries in utero
- Fluorescence in situ hybridization for cervical cancer screening
- Fluorescence spectroscopy for prostate cancer diagnosis
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G
- Gastrointestinal electrical stimulation for obesity
- Gastroparesis evaluations
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H
- Hand and arm transplants
- Hidradenitis suppurativa surgery
- Home spirometry
- Home uterine activity monitoring
- Home-use light box therapy for seasonal affective disorder
- Hydrogel spacer use during radiotherapy for prostate cancer
- Hypoglossal nerve stimulation
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I
- IFuse implant system
- Immune cell function assays in transplantation
- Inhaled nitric oxide
- Injectable bulking agents — fecal incontinence
- Intermittent pneumatic compression for peripheral artery disease
- Intracranial hypertension stent
- Intravascular ultrasound
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K
- Ketone monitor for ketogenic diet in epilepsy
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L
- Laser interstitial thermal therapy for drug-resistant epilepsy
- Latera absorbable nasal implant
- Lipoprotein apheresis
- Lung transplants
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M
- Manipulation under anesthesia (hip and elbow)
- MarginProbe®
- Measurement of serum antibodies to Infliximab and Adalimumab
- Medical alert devices
- Medical three-dimensional printing
- Melody™ transcatheter pulmonary valve replacement
- Microwave thermotherapy for breast cancer
- Microwave thermotherapy for lung and kidney tumors
- Myocardial strain imaging
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N
- Neuroablation for chronic foot pain
- Nonpharmacologic treatments for chronic vertigo
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O
- Oral nutritional supplements
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P
- Pancreas transplantation
- Pediatric intensive feeding programs
- Pediatric rhinoplasty
- Pediatric turbinoplasty
- Percutaneous peripheral nerve stimulators for chronic nerve pain
- Percutaneous sacroplasty
- Peripheral nerve stimulators for chronic nerve pain
- Peristeen® anal irrigation system
- Peroral endoscopic myotomy
- Pet therapy
- Phototherapy and photochemotherapy for skin conditions
- Phrenic (diaphragmatic) nerve stimulation
- Plastic reconstructive surgery
- Platelet rich plasma for nonhealing diabetic wounds
- Postural orthostatic tachycardia syndrome treatment with physical therapy
- Prescription digital therapeuticss for contraception
- Prolotherapy
- Prostatic urethral lift/UroLift for benign prostatic hypertrophy
- Pulsed dye laser for port-wine stain and infantile hemangioma
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R
- Radiofrequency ablation for nasal valve collapse
- Radiofrequency ablation of genicular nerves for knee pain
- Re-SET-O
- Renal denervation
- Robotic orthoses – lower limb
- Robotic orthoses – upper limb
- Room humidifiers
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S
- Sacral nerve modulation/stimulation
- Scoliosis vertebral body tethering and stapling
- Shoe lifts for leg length discrepancy
- Sialendoscopy and lithotripsy for salivary stones
- Skin surgery after massive weight loss
- Smell and taste dysfunction testing
- Specialized infant formula
- Speech therapy
- Sphenopalatine ganglion block injections for headache
- Stereotactic navigation in sinus surgery
- Supraglottoplasty and laryngoplasty
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T
- Tactile breast imaging
- Therapeutic contact lenses
- Three-dimensional imaging and interpretation
- Topical oxygen therapy
- Total artificial heart
- Transanal radiofrequency for fecal incontinence
- Transcatheter coronary infusion of supersaturated oxygen therapy in acute myocardial infarction
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V
- Vaginitis diagnostic testing
- Vagus nerve stimulation for post-stroke upper limb rehabilitation
- Vestibular evoked myogenic potential testing
- Video head impulse testing
- Virtual colonoscopy – CT colonography
- Vitamin D screening
- Volatile organic compounds for urinary tract infection
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W
- Wearable dialysis and implantable artificial kidneys
- Wheelchair mounted robotic arm – Kinova Jaco2
- Wireless pulmonary artery pressure monitoring devices for heart failure
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X
- XEN® gel stent for glaucoma
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