Presbyterian Health Plan, Inc. Medical Policy Manual

A

• Ambulance Services, MPM 1.1
• Autism Spectrum Disorders: Diagnosis and Treatment, MPM 1.4
• Autologous Chondrocyte Implantation (Carticel), MPM 3.2

B

• Balloon Dilation for ENT Procedures, MPM 2.12
• Bariatric Surgery (Weight Loss Surgery) for Medicare, MPM 2.82
• Bariatric Surgery (Weight Loss Surgery) for Non-Medicare, MPM 2.81
• Bioimpedance Spectroscopy for the Assessment of Lymphedema, MPM 5.10
• Blepharoplasty/Ptosis Surgery, MPM 2.7
• Bone Anchored Hearing Aid (BAHA), MPM 2.9
• Breast Cancer Recurrence and Predictive Genetic Testing, for Medicare, MPM 33.0
• Breast Surgical Procedures, MPM 27.0
• Bronchial Thermoplasty For Treatment of Asthma, MPM 2.13

C

• Cancer Clinical Trials, Routine Patient Care Costs- For Group Health Coverage including self-insured & Centennial, MPM 3.7
• Cervical and Lumbar Spinal Procedures, MPM 25.1
• Chimeric Antigen Receptor (CAR) T-cell Therapy, MPM 32.0
• Cholecystectomy, MPM 3.9
• Clinical Trial Coverage for Members Enrolled in a Medicare Plan, MPM 3.8
• Continuous Glucose Monitoring Systems (See DME: Diabetic Equipment, MPM 4.4)
• Corneal Cross-Linking for Keratoconus and Ectasia, MPM 28.0
• Coronary Computed Tomography (64-Slice CT), MPM 3.4
• Cranial Orthotic Devices, (See DME: Orthotics and Prosthetics, MPM 4.6)

D

• Diapers (for Centennial Care members only), MPM 4.8
• Durable Medical Equipment: Alternating Electromagnetic Field Therapy for Glioblastoma, MPM 34.0
• Durable Medical Equipment: Diabetic Equipment, MPM 4.4
• Durable Medical Equipment: Lymphedema Pumps/Garments, MPM 26.0
• Durable Medical Equipment: Miscellaneous, MPM 4.5
• Durable Medical Equipment: Orthotics and Prosthetics, MPM 4.6
• Durable Medical Equipment: Pneumatic Compression Devices, MPM 5.0
• Durable Medical Equipment: Rehabilitation and Mobility Devices, MPM 4.2
• Durable Medical Equipment: Respiratory Devices, MPM 4.3

E

• Electric Bioimpedance for Cardiac Output Monitoring (BioZ), MPM 5.4
• Epidural Corticosteroid Injections for Back Pain, MPM 5.9
• Exhaled Nitric Oxide Testing for the Diagnosis/Management of Asthma, MPM 5.5
• Extracorporeal Photopheresis, MPM 5.7
• Extracorporeal Shock Wave Therapy for Musculoskeletal Disorders, MPM 5.6

F

• Fecal Microbiota Transplantation FMT, MPM 6.1
• Foot Splints for Club Foot (See DME: Orthotics and Prosthetics, MPM 4.6)

G

• Gastric Electric Stimulation for the Treatment of Chronic Gastroparesis, MPM 7.2
• Gender Dysphoria/Gender Identity Disorder Treatment, MPM 7.3
• Genesight Assay for Refractory Major Depression (Medicare), MPM 30.0
• Genetic and Genomic Testing, MPM 7.1
• Genetic Testing: Cologuard for Colorectal Cancer Screening, MPM 7.4
• Genetic Testing for Cutaneous Melanoma for Medicare, MPM 7.7
• Genetic Testing for Lynch Syndrome, MPM 7.5
• Genetic Testing for Pancreatic Cyst (PathfinderTG®/PancraGen™), MPM 7.6
• Genetic Testing for Prostate Cancer, MPM 7.8
• Genetic Testing for Uveal Melanoma, MPM 7.9

H

• Hip Arthroscopy for Femoroacetabular Impingement (FAI), MPM 8.7
• Hyperbaric Oxygen Therapy, MPM 8.6
• Hysterectomy, MPM 8.9

I

• Implantable Cardioverter Defibrillators (ICD), MPM 9.5
• Intervertebral Differential Dynamics Therapy (IDD Therapy), MPM 9.6
• Intradiscal Electrothermal Therapy (IDET) (See Thermal Intradiscal Procedures, MPM. 20.7)

L

• LINX Reflux Management System for the Treatment of GERD, MPM 12.2

M

• Magnetoencephalography, MPM 13.1
• Medicaid Home Health Services, MPM 13.6
• Meniscal Allograft Transplantation, MPM 13.3
• Minimally Invasive Lumbar Decompression MILD and Percutaneous Image Guided Lumbar Decompression (PILD), MPM 13.5
• Minimally Invasive Total Hip Arthroplasty, MPM 13.4
• Mobile Cardiac Outpatient Telemetry™ MCOT™, MPM 13.2

N

• Next Generation Sequencing for Medicaid and Medicare, MPM 29.0
• Non-Invasive Prenatal Testing (NIPT), MPM 20.15
• Nucleoplasty (See Thermal Intradiscal Procedures, MPM 20.7)

O

• Obstetric Ultrasound, 2D, 3D, 4D or 5D, MPM 15.4
• Osteogenic Bone Growth Stimulators for Commercial, MPM 15.1
• Osteogenic Bone Growth Stimulators for Medicare/Medicaid, MPM 15.2

P

• Panniculectomy and Abdominoplasty, MPM 16.5
• Paravertebral Facet Joint Denervation, MPM 16.6
• Percutaneous Coronary Interventions MPM 9.7
• Percutaneous Neuromodulation Therapy, MPM 16.8
• Pharmacogenetic Testing for Warfarin Dosing (See Genetic and Genomic Testing, MPM 7.1)
• Photodynamic Therapy for Ocular Conditions, MPM 16.15
• Photodynamic Therapy for Skin and Cancer Conditions, MPM 16.9
• Plasma Exchange: Therapeutic Apheresis, for Medicare, MPM 16.11
• Plasma Exchange: Therapeutic Apheresis, for Commercial and Medicaid, MPM 16.12
• Platelet-Rich Plasma and Platelet-Derived Growth Factor Products, for the Treatment of Wounds and Other Injuries, MPM 16.16
• Positron Emission Tomography (PET), MPM 16.1
• Prophylactic Mastectomy and Oophorectomy, with or without Hysterectomy, for Prevention of Cancer, MPM 16.10
• Prostate Ablation Treatment for Prostate Cancer, MPM 12.3
• Proton Beam Therapy (See Radiation Oncology: Proton Beam Therapy, MPM 16.14)

R

• Radiation Oncology: Brachytherapy, MPM 18.7
• Radiation Oncology: Proton Beam Therapy, MPM 16.14
• Restorative/Reconstructive/Cosmetic Surgery and Treatment, MPM 18.5

S

• Secca® Procedure for Fecal Incontinence, MPM 19.8
• Sleep Studies, Polysomnography, MPM 31.0
• Subtalar Arthroereisis Implants for Pediatric Patients, MPM 19.6

T

• Thermal Intradiscal Procedures, MPM 20.7
• Tissue-Engineered/Bioengineered Skin Substitutes (Application and Use), MPM 35.0
• Tonsillectomy, MPM 20.0
• Total Ankle Replacement, MPM 20.10
• Total Hip Resurfacing, MPM 20.9
• Total Joint Replacement, MPM 20.14
• Transcranial Magnetic Stimulation for Treatment Resistant Depression for Commercial, MPM 20.16
• Transcranial Magnetic Stimulation for Treatment Resistant Depression for Medicare, MPM 20.11
• Transoral Incisionless Fundoplication (TIF) for Treatment of GERD, MPM 20.12
• Transplants, Bone Marrow and Peripheral Stem Cell, MPM 20.3
• Transplants, Organ, MPM 20.6

V

• Vagus Nerve Stimulation, MPM 22.4
• Varicose Vein and Venous Stasis Disease of Lower Extremity Procedures, MPM 22.1
• Virtual Colonoscopy, MPM 22.0

W

• Whole Breast Ultrasound, Semi-Automatic, MPM 24.1
• Wireless Capsule Endoscopy WCE, MPM 24.0

X

• X-STOP® Interspinous Process Decompression (IPD) System, MPM 25.0