Policy Title  |
Date Posted |
Effective Date |
| Acoustic Pharyngometers & SNAP Testing |
10/06/08 |
10/06/08 |
| Actigraphy |
10/19/09 |
10/19/09 |
| Acne Surgery |
03/01/06 |
04/01/06 |
| Adult Growth Hormone |
03/01/07 |
03/01/07 |
| Ambulatory Blood Pressure Monitoring |
09/18/09 |
09/18/09 |
| Ambulatory Event Monitors and Mobile Outpatient Cardiac Telemetry |
06/06/08 |
06/06/08 |
| Angiotensin Converting Enzyme Inhibitors (ACEIs), and Angiotensin II Receptor Antagonists (ARBS), and Combinations Prior Authorization Criteria |
03/02/10 |
04/01/10 |
Angiotensin Converting Enzyme Inhibitors and
Angiotensin II Receptor Antagonists
Prior Authorization Criteria |
02/25/08 |
01/01/08 |
| Antidepressant Agents Prior Authorization Criteria |
12/31/09 |
12/31/09 |
| Apolipoprotein B in the Risk Assessment and Management of Cardiovascular Disease |
02/11/09 |
03/13/09 |
| Apolipoprotein E Genotype or Phenotype in the Management of Cardiovascular Disease |
02/11/09 |
03/13/09 |
| Artificial Intervertebral Disc: Cervical Spine |
09/23/08 |
09/23/08 |
| Artificial Intervertebral Disc: Lumbar Spine |
02/22/10 |
09/23/08 |
| Automated Percutaneous Discectomy |
02/08/10 |
02/08/10 |
| Automated Point-of-Care Devices for Nerve Conduction Testing |
02/08/10 |
10/13/08 |
| Balloon Sinuplasty for Treatment of Chronic Sinusitis |
12/15/08 |
12/15/08 |
| Barrett's Esophagus Treatments |
02/08/10 |
02/26/09 |
| Bone Anchored Hearing Aids (BAHA) |
06/01/06 |
07/01/06 |
| Bone Mineral Density Studies |
09/18/09 |
10/19/09 |
| Botulinum Toxin (BT) (i.e. Botox®, Myobloc®) |
02/08/10 |
10/19/09 |
| BRCA I and BRCA II Testing |
12/04/09 |
12/04/09 |
| Cardiac Computed Tomography |
02/22/10 |
02/22/10 |
| Cardiovascular Magnetic Resonance (CMR) |
11/01/07 |
11/01/07 |
| Cardioverter - Defibrillators |
10/31/08 |
10/31/08 |
| Cochlear Implant |
03/01/07 |
10/31/06 |
Computed Tomography (CT) to Detect
Coronary Artery Calcification |
02/08/10 |
11/14/08 |
| Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast |
11/02/09 |
11/02/09 |
| Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid |
09/09/09 |
09/09/09 |
| Continuous Passive Motion for Home Use |
03/08/10 |
07/01/07 |
| Contrast-Enhanced Computed Tomography Angiography (CTA) for Coronary Artery Evaluation |
02/08/10 |
12/15/08 |
| COX-2 Inhibitors Prior Authorization Criteria |
02/25/08 |
10/01/07 |
| CTA and MRA of the Chest (excluding the Heart) |
07/23/09 |
12/15/08 |
| CTA and MRA of the Head, Neck, Abdomen, Pelvis and Extremities |
11/14/08 |
12/15/08 |
| Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis of Gastrointestinal Origin |
10/19/09 |
10/19/09 |
| Decompression of the Intervertebral Disc Using Laser (Laser Discectomy) or Radiofrequency (DISC Nucleoplasty™) Energy |
02/08/10 |
02/08/10 |
| Deep Brain Stimulation of the Thalamus |
03/01/07 |
11/01/06 |
| Deflux Injection for Vesicoureteral Reflux (VUR) |
12/30/05 |
02/01/06 |
| Electrical Stimulation Devices for Home Use |
02/11/09 |
02/11/09 |
| Electromyography (EMG) Nerve Conduction Studies (NCS) and Other Electrodiagnostic (EDX) Related Services |
10/13/08 |
11/12/08 |
| Enhanced External Counterpulsation (EECP) |
11/01/07 |
11/01/07 |
| Equipment for Cold Therapy |
08/01/05 |
07/01/04 |
| Esophageal pH Monitoring |
06/30/06 |
05/01/06 |
| Exhaled Nitric Oxide and Exhaled Breath Condensate ph Measurement for Respiratory Disorders |
02/08/10 |
06/30/09 |
| Extended Fundus Photography (i.e. Optomap®) |
11/01/06 |
01/01/06 |
| Extracorporal Shock Wave Therapy (ESWT) for Plantar Fasciitis |
12/30/05 |
01/01/06 |
| Extracranial Carotid Angioplasty/Stenting (CAS) |
06/01/07 |
07/01/07 |
Eye Movement Desensitization and Reprocessing (EMDR) for Acute Stress Disorder and Post Traumatic Stress Disorder (PTSD) |
11/01/07 |
11/01/07 |
| Facet Joint Denervation |
02/08/10 |
02/08/10 |
| Fetal Fibronectin |
05/01/07 |
05/01/07 |
| Gene Expression Assay for Breast Cancer Treatment |
06/01/07 |
07/01/07 |
| Genetic Testing for Congenital Long QT Syndrome |
07/13/09 |
08/12/09 |
| High-Density Lipoprotein Subclass Testing in the Diagnosis and Management of Cardiovascular Disease |
02/11/09 |
03/13/09 |
| High Dose Rate (HDR) Breast Brachytherapy with HDR Radioactive Source via MammoSite Catheter |
06/01/07 |
07/01/07 |
| High-Sensitivity C-Reactive Protein |
02/11/09 |
03/13/09 |
| Home Phototherapy |
03/01/07 |
04/01/07 |
| Home Prothrombin Time Monitoring |
09/18/09 |
09/18/09 |
| Home Uterine Activity Monitoring |
03/08/10 |
03/08/10 |
| Homocysteine Testing |
08/01/05 |
04/01/04 |
| Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease |
02/11/09 |
03/13/09 |
| Hyperbaric Oxygen (HBO) Therapy |
05/03/04 |
08/29/03 |
| Identification of Microorganisms Using Nucleic Acid Probes |
06/16/09 |
06/16/09 |
| Immune Globulin Therapy (IVIG) |
03/01/07 |
04/01/07 |
Implanted Peripheral Nerve Stimulator (PNS) for Pain Control |
01/26/10 |
01/26/10 |
| Insulin Pump |
12/29/06 |
02/01/07 |
| Intensity Modulated Radiation Therapy (IMRT) |
02/08/10 |
1/30/09 |
| Interspinous Distraction Devices (Spacers) |
02/08/10 |
02/08/10 |
| Intra-articular Hyaluronan Injections for Osteoarthritis of the Knee |
02/08/10 |
12/24/08 |
| Keratoprosthesis |
07/09/09 |
07/09/09 |
| Ketogenic Diet as a Treatment of Refractory Epilepsy |
03/08/10 |
01/12/09 |
| Laser Assisted Uvulopalatopharyngoplasty (LAUP) |
12/30/05 |
02/01/06 |
| LASIK (laser in situ keratomileusis) |
11/01/07 |
02/15/07 |
| Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk |
02/11/09 |
03/13/09 |
| Lipoprotein(a) Enzyme Immunoassay in the Management of Cardiovascular Disease |
02/11/09 |
03/13/09 |
| Liver Tumors, Treatment of |
03/11/09 |
03/11/09 |
| Lysis of Epidural Adhesions |
02/08/10 |
02/08/10 |
| Magnetic Resonance Angiography (MRA) |
03/31/06 |
05/01/06 |
| Magnetic Resonance Imaging (MRI) Breast |
03/01/07 |
01/01/07 |
| Magnetic Resonance Spectroscopy |
06/16/09 |
02/14/05 |
| Monitored and General Anesthesia Services |
05/01/07 |
01/01/07 |
| Nuchal Translucency |
03/30/07 |
01/01/07 |
| Oscillation Vest, Chest |
12/29/06 |
02/01/07 |
| Pachymetry |
12/30/05 |
02/01/06 |
| Panniculectomy and Abdominoplasty |
09/18/09 |
10/19/09 |
| Pediatric Growth Hormone |
02/08/10 |
08/18/08 |
| Percutaneous Axial Anterior Lumbar Fusion |
02/08/10 |
02/08/10 |
| Percutaneous Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty |
02/08/10 |
02/08/10 |
| Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty |
07/23/09 |
07/23/09 |
| Polysomnography and Sleep Studies |
02/08/10 |
09/18/09 |
| Positron Emission Tomography (PET) |
02/08/10 |
10/19/09 |
| Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors |
08/22/08 |
08/22/08 |
| Radiofrequency Catheter Ablation of the Pulmonary Veins as Treatment for Atrial Fibrillation |
01/26/10 |
01/26/10 |
| Regional Nerve Blocks and General Anesthesia |
09/30/05 |
11/01/05 |
| Rhinomanometry & Acoustic/Optical Rhinometry |
10/06/08 |
10/06/08 |
| Sacral Nerve Modulation/Stimulation for Urinary Dysfunction |
10/19/09 |
10/19/09 |
| Scanning Laser Ophthalmoscopy (SLO) for Glaucoma and Optical Coherence Tomography (OCT) for Retinal Conditions |
09/25/07 |
11/01/07 |
| Sensorimotor and Neurobehavioral Status Exams for Optometric Providers |
12/30/05 |
01/01/06 |
| Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease |
11/19/09 |
11/05/08 |
| Sleeve Gastrectomy |
02/08/10 |
02/08/10 |
| Small Bowel/Liver and Multivisceral Transplant |
01/26/10 |
02/25/10 |
| Small Low-Density Lipoprotein (LDL) Particles and Concentration of LDL Particles in Cardiac Risk Assessment and Management |
02/11/09 |
03/13/09 |
| Statin Step Therapy Prior Authorization Criteria Policy |
11/06/09 |
01/01/10 |
| Stereotactic Radiosurgery and Radiotherapy |
06/30/09 |
06/30/09 |
| Subtalar Arthroeresis |
02/08/10 |
01/27/09 |
| Synagis (Respiratory Syncytial Virus [RSV]) Prior Authorization Criteria |
11/06/09 |
12/07/09 |
| Testing for Vitamin D Deficiency |
03/08/10 |
08/26/09 |
| Thoracic Bioimpedance as a measure of Cardiac Hemodynamics in the Ambulatory Care - Outpatient Setting |
07/27/09 |
08/26/09 |
| Total Body Plethysmography |
06/16/09 |
07/16/09 |
| Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease |
12/15/09 |
12/15/09 |
| Transplantation for Chondral Defects |
12/15/09 |
01/14/10 |
| Treatment of Hyperhidrosis |
01/26/10 |
01/26/10 |
| Treatment of Tinnitus |
06/30/09 |
06/30/09 |
| Tumor Markers CA-15-3 and CA-27.29 |
07/01/05 |
07/01/03 |
| Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis |
08/24/09 |
02/27/07 |
| Uvulopalatopharyngoplasty (UPPP) and Tongue Base Reduction Surgery |
03/23/09 |
01/01/07 |
| Vacuum Assisted Wound Closure (VAC) |
05/15/07 |
06/15/07 |
| Vagus Nerve Stimulation |
10/09/08 |
10/08/08 |
| Varicose Veins |
02/08/10 |
11/18/09 |
| Video EEG Monitoring |
12/29/06 |
02/01/07 |
| Virtual Colonoscopy/CT Colonography |
12/31/09 |
12/31/09 |
| Water-Induced Thermotherapy for Benign Prostate Hypertrophy (BPH) |
12/30/05 |
02/01/06 |
| Wireless Capsule Endoscopy |
03/01/07 |
01/01/07 |
| Wound Care: Skin Substitutes and Growth Factors |
11/14/08 |
05/21/08 |
| Xolair Prior Authorization Criteria |
09/05/08 |
09/05/08 |
