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Internal Medical Policy Search

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Showing 1– 50 of 290 Results
Policy ID Title Last Updated Category
01.01.38 Negative Pressure Wound Therapy, PICO™ system, SNaP® system, Topical Negative Pressure therapy, Vacuum Assisted Closure therapy Open a PDF 2019-01-02 Skin (Dermatology)
1.01.00 Durable Medical Equipment (DME) - Standard and Non-Standard, Home Medical Equipment Open a PDF 2018-10-02 Durable Medical Equipment & Supplies
1.01.01 Electrical Stimulation: Transcutaneous Electrical Nerve (TENS), Percutaneous Electrical Nerve (PENS), H-Wave and Interferential Stimulators (IFS), Percutaneous Neuromodulation Therapy, Bionicare® Open a PDF 2019-08-12 Durable Medical Equipment & Supplies
1.01.02 Continuous Passive Motion Device (CPM) in the Home Setting Open a PDF 2018-10-02 Durable Medical Equipment & Supplies
1.01.03 Augmentative and Alternative Communication Systems: AAC, Dynavox, Introtalker, VoiceMate, Walker Talker, Say-It-All, Speech Generating Devices (SGD) Open a PDF 2019-01-18 Durable Medical Equipment & Supplies
1.01.04 Blood Pressure Monitoring, Automated, Ambulatory Open a PDF 2019-01-18 Heart & Blood Vessels (Cardiovascular)
1.01.05 Home and Community Oxygen Therapy: Long Term Oxygen Therapy (LTOT), High Altitude Stimulation Test (HAST), Oxygen Concentrator, Portable Oxygen Policy Open a PDF 2019-04-30 Home Care
1.01.06 Positive Airway Pressure Devices: CPAP, BiPAP, APAP, DPAP, C-FLex Open a PDF 2019-08-12 Durable Medical Equipment & Supplies
1.01.07 Oral Appliances for the Treatment of Sleep Related Breathing Disorders: Mandibular Repositioning Device, Nocturnal Airway Patency Appliance (NAPA), Tongue Retaining Device Open a PDF 2019-04-30 Lungs (Respiratory)
1.01.08 Patient Lifts (e.g., Hoyer, Saralift), Seat Lift Chair Mechanisms and Ceiling Lifts Open a PDF 2019-08-12 Home Care
1.01.12 Home Exercise/Physical Therapy Equipment (e.g., Home Gym, Jacuzzi) Open a PDF 2019-01-18 Home Care
1.01.14 Surgical Stockings (e.g., Gradient Compression/GCS, Jobst, Sigvaris, TEDs) and Compression Garments (e.g., Arm Assist, Belisse Compressure Bra, Lymphedema, Mastectomy, Circaid, Juzo, Reid Sleeves) Open a PDF 2018-10-02 Durable Medical Equipment & Supplies
1.01.15 Airway Clearance Devices: Oscillatory Devices - ABI Vest, Acapella, Flutter Valve, Lung Flute®, ThAIRapy Vest; Mechanical Percussors and Assisted Cough Devices - Cofflator, Cough-Alator, In-Exsufflator Open a PDF 2019-01-18 Lungs (Respiratory)
1.01.16 Wheelchairs and Power Operated Vehicles (POVs) (e.g., Scooters) Open a PDF 2019-08-12 Durable Medical Equipment & Supplies
1.01.17 Pneumatic Compression Devices/Lymphedema Pump/Sleeve (e.g., Flexitouch™) Open a PDF 2019-06-04 Durable Medical Equipment & Supplies
1.01.18 External Prosthetic Devices: C-leg, Intelligent prosthesis, microprocessor-controlled lower limbs, Ossur Rheo, Vacuum-assisted-socket system (VASS) Open a PDF 2019-04-30 Miscellaneous
1.01.19 Pelvic Floor Electrical Stimulation (PFES) as a Treatment of Urinary or Fecal Incontinence, Intravaginal Stimulation Open a PDF 2019-08-22 Urinary System (Genitourinary)
1.01.21 Cryotherapy, Cold Therapy, Ice Therapy Open a PDF 2019-08-12 Bone & Joints (Orthopedic)
1.01.24 Phototherapy/Light Therapy for Seasonal Affective Disorder (SAD) Open a PDF 2018-11-26 Behavioral Health (Psychology)
1.01.25 Orthotics (e.g., OttoBock E-Mag Active KAFO, OttoBock SensorWalk Electronic KAFO, MYOMO mPower 1000 arm brace) Open a PDF 2019-06-04 Bone & Joints (Orthopedic)
1.01.30 CGMS, Continuous glucose monitor, DexCom STS, Freestyle Navigator, Interstitial glucose monitoring, MiniMed CGMS® System Gold™, MiniMed Guardian® Real-Time, MiniMed Paradigm Revel® Real-Time system, DexCom G5®,Wrist glucose monitor, Continuous subcutaneous insulin infusion, CSII, Insulin pump therapy Open a PDF 2018-11-19 Diabetes (Endocrinology)
1.01.31 End-Diastolic Pneumatic Compression (e.g., Circulator) Boot Open a PDF 2019-06-04 Heart & Blood Vessels (Cardiovascular)
1.01.32 Cranial Orthotics/Helmet for Asymmetry (e.g., Dynamic Orthotic Cranioplasty, DOC) Open a PDF 2019-01-18 Children's Health (Pediatrics)
1.01.33 Home Phototherapy for Hyperbilirubinemia (e.g., Biliblanket, Bili Lights) Open a PDF 2018-10-02 Children's Health (Pediatrics)
1.01.35 Dynamic Adjustable Braces/Joint Extension Device (e.g., Dynasplint™, EMPI Advance™, LMB Proglide™, Ultraflex™ Open a PDF 2019-04-30 Bone & Joints (Orthopedic)
1.01.39 Breast Pumps Open a PDF 2019-06-04 Durable Medical Equipment & Supplies
1.01.41 Foot Orthotics, Arch Supports, Shoe Inserts Open a PDF 2018-10-02 Feet (Podiatry)
1.01.42 Home Automatic External Defibrillator (AEDs) and Wearable Defibrillator Vests (WCDs): HeartStart, LIFECOR Open a PDF 2019-06-04 Heart & Blood Vessels (Cardiovascular)
1.01.44 Home Prothrombin Time Monitor (e.g., Acusure™, CoaguChek®, International Normalized Ratio [INR], Prothrombin Time [PTT], Protime, Rubicon®) Policy Open a PDF 2019-08-12 Home Care
1.01.46 Standing Devices and Gait Trainers, Stander Open a PDF 2019-04-30 Durable Medical Equipment & Supplies
1.01.47 Cervical Traction Devices (e.g., HomeTrac Deluxe, Saunders Cervical HomeTrac, Hydraulic, Over-The-Door, Pneumatic Cervical, Pronex) Open a PDF 2019-06-04 Durable Medical Equipment & Supplies
1.01.48 Neuromuscular Electrical Stimulation (FNS, NMES, TES, VitalStim®) Open a PDF 2019-08-15 Durable Medical Equipment & Supplies
1.01.49 Telemedicine and Telehealth Open a PDF 2019-06-04 Home Care
1.01.50 Lumbar Traction: Vertebral Axial Decompression and Home Lumbar Traction Devices - ComfortTrac, Decompression Reduction Stabilization (DRS) System, HomeTrac, Orthotrac, VAX-D Open a PDF 2019-08-22 Bone & Joints (Orthopedic)
1.01.51 Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis: Triple Play VT®, Venodyne, VascuTherm2 Open a PDF 2019-08-22 Durable Medical Equipment & Supplies
1.01.52 Vitrectomy Chair/ Face-Down Positioning System Open a PDF 2019-06-04 Durable Medical Equipment & Supplies
1.01.53 Bone Growth Stimulators for the Appendicular Skeleton Open a PDF 2019-04-30 Bone & Joints (Orthopedic)
10.01.01 Breast Reconstruction Surgery Open a PDF 2018-10-02 Cosmetic / Reconstructive Surgery
10.01.02 Chiropractic Care Open a PDF 2019-04-30 Chiropractic
10.01.03 Enteral Formula/Nutrition, Enteral Therapy, Probiotics, Tube Feeding Open a PDF 2019-04-30 Food (Nutrition)
10.01.05 Prostate Cancer Screening, Detection and Monitoring (e.g., Digital Rectal Exam - DRE, PCA3Plus, Prostate Specific Antigen - PSA, Prostatic Acid Phosphatase - Male PAP Test) Open a PDF 2019-08-15 Urinary System (Genitourinary)
10.01.07 Ambulance: Land/Ground Open a PDF 2019-06-04 Miscellaneous
10.01.08 Coverage for Dependents with Disabilities Open a PDF 2019-08-12 Miscellaneous
10.01.09 Early Intervention Services Open a PDF 2018-11-26 Children's Health (Pediatrics)
10.01.10 Second Medical and Second Surgical Opinions, Confirmatory Consultation Open a PDF 2019-06-04 Miscellaneous
10.01.11 Disability Determination for Extension of Benefits after Contract Termination Open a PDF 2018-10-09 Miscellaneous
10.01.12 Emergency Care Services Open a PDF 2019-06-04 Miscellaneous
11.01.01 Medical/Non-Surgical Weight Management Programs and Services, Indirect Calorimetry, Intensive/high intensity lifestyle counseling program Open a PDF 2019-01-18 Miscellaneous
11.01.03 Experimental or Investigational Services Open a PDF 2019-04-30 Miscellaneous
11.01.04 Total Parenteral Nutrition (TPN), Intradialytic Parenteral Nutrition (IDPN), Intraperitoneal Nutrition (IPN), or Hyperalimentation Open a PDF 2019-04-30 Food (Nutrition)
Showing 1– 50 of 290 Results