Provider PortalsMedical Policy Manual Presbyterian Health Plan, Inc. Medical Policy ManualCurrently selected Appeals & Grievances Appeals & Grievances Form Reference & Guides Medical, Pharmacy, and Behavioral HealthClinical Practice GuidelinesPresbyterian Care ConnectionNotifiable Diseases / Conditions in New Mexico Training & Education Provider Manuals, Training & OutreachPresbyterian ECHO About Presbyterian ECHOFrequently Asked QuestionsPresbyterian ECHO Past Recordings Hospital Resources Ethics CommitteeHuman Research Protections & Institutional Review BoardMedical Education Continuing Medical EducationClinical Rotations Presbyterian Medical Staff AffairsResearch Grants and Sponsored Awards Home|Providers|Tools & Resources|Medical Policy Manual|Presbyterian Health Plan, Inc. Medical Policy Manual Presbyterian Health Plan, Inc. Medical Policy Manual Page Image Page ContentA 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 Bariatric Surgery for Pediatric Population, MPM 40.0 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, 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, 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 Facet Joint Interventions for Pain Management (Formerly Paravertebral Facet Joint Denervation), MPM 16.6 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 for Medicare, MPM 30.0 Genetic and Genomic Testing (Disease Specific), 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, InvisionFirst Liquid Biopsy for Lung Cancer, MPM 37.0 Genetic Testing for Lynch Syndrome, MPM 7.5 Genetic Testing for Non-Invasive Prenatal Testing (NIPT) (Formerly Non-Invasive Prenatal Testing (NIPT)), MPM 20.15 Genetic Testing for Pancreatic Cyst (PathfinderTG®/PancraGen™), MPM 7.6 Genetic Testing, Plasma-Based Genomic Profiling in Solid Tumors, MPM 39.0 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, 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, MPM 15.2 P Panniculectomy and Abdominoplasty, MPM 16.5 Paravertebral Facet Joint Denervation (See Facet Joint Interventions for Pain Management, 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, (includes IDET and Nucleoplasty), 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 Hip and Knee for Non-Medicare, MPM 20.14 Total Joint Replacement Hip and Knee for Medicare, MPM 20.13 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 U Unicompartmental Knee Replacement, MPM 41.0 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 Additional Content Back To Top Sidebar Content