Anthem Blue Cross : By Alpha

By Alpha

PW_A111727
Medical Policies 
 
The “Last Review Date” set forth in the Medical Policy is the most recent date the Medical Policy and Technology Assessment Committee has reviewed or revised the policy. This is not necessarily coincident with the “Current Effective Date” which is also shown on the policy. For example, we may require lead time in order to program a medical policy on our claims systems. In cases where a new or revised policy results in the denial of benefits for services which have historically been covered, we may opt to provide advance notice of the changes prior to the policy taking effect. To confirm the effective date of a particular policy for your state or region, please contact us. 
 
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 
 
A  
Abatacept (Orencia®)
Adjustable Cranial Orthosis for Synostotic and Non-Synostotic Indications
Adoptive Immunotherapy and Cellular Therapy
Aerosolized Anti-infective Therapy for Sinusitis
Allergy Testing
Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering
Analysis of Fecal DNA for Colorectal Cancer Screening and Surveillance
Analysis of KRAS Status in Metastatic Colorectal Cancer
Analysis of Proteomic Patterns
Anterior Segment Optical Coherence Tomography
Antineoplaston Therapy
Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
Artificial Intervertebral Discs
Artificial Retinal Devices
Autologous and Allogeneic Islet Cell Transplantation
Autologous Cell Therapy for the Treatment of Damaged Myocardium
Autologous, Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Automated External Defibrillators for Home Use
Automated Meibomian Gland Evacuation
Automated Nerve Conduction Testing
Axial Lumbar Interbody Fusion
 
 
B  
Balloon Sinuplasty
BCR-ABL Mutation Analysis
Bevacizumab (Avastin®) for Oncologic Indications
Biocompartmental Knee Arthroplasty
Biofeedback for Constipation or Fecal Incontinence
Biofeedback for Muscle Re-education and Chronic Pain
Biofeedback Therapy and Neurofeedback
Biomagnetic Therapy
Bone Anchored Hearing Aids
Botulinum Toxin
Brachytherapy for Oncologic Indications
Breast Ductal Examination and Fluid Cytology Analysis
Breast Procedures, including Reconstructive Surgery, Implants and Other Breast Procedures
 
 
C  
Canaloplasty
Cardiac Ion Channel Genetic Testing
Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure
Carotid Intimal Medial Thickness Measurement
Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement
Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
Cerebral Perfusion Imaging Using Computed Tomography
Cerebral Perfusion Studies using Diffusion and Perfusion Magnetic Resonance Imaging
Cervical and Thoracic Discography
Cetuximab (Erbitux®)
Chelation Therapy
Coblation® Use for Musculoskeletal Conditions
Cochlear Implants and Auditory Brainstem Implants
Cognitive Rehabilitation
Computed Tomography to Detect Coronary Artery Calcification
Computer Analysis of Electrocardiography (ECG)
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures
Continuous Passive Motion Devices
Convection Enhanced Delivery of Therapeutic Agents to the Brain
Cooling Devices and Combined Cooling/Heating Devices in the Outpatient Setting
Corneal Hysteresis
Coronary Artery Imaging: Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA) and Coronary Magnetic Resonance Angiography (MRA)
Cosmetic and Reconstructive Services of the Head and Neck
Cosmetic and Reconstructive Services of the Trunk and Groin
Cosmetic and Reconstructive Services: Skin Related
Cryoablation for Plantar Fasciitis and Plantar Fibroma
Cryopreservation of Oocytes or Ovarian Tissue
Cryosurgical Ablation of Solid Tumors Outside the Liver
CT Colonography (Virtual Colonoscopy) as a Screening or Diagnostic Test for Colorectal Cancer
CT Scans with or without Computer Assisted Detection (CAD) for Lung Cancer Screening
 
 
D  
Deep Brain Stimulation
Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor in Patients with Metastatic Cancer
Diagnosis of Sleep Disorders
Diagnostic Genetic Testing of a Potentially Affected Individual (Adult or Child)
Diaphragmatic/Phrenic Nerve Stimulation
Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation
Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
 
 
E  
Electrical Bone Growth Stimulation
Electrical Stimulation and Electromagnetic Therapy for Wound Healing
Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
Electrocardiographic (ECG) Body Surface Mapping
Electromagnetic Navigational Bronchoscopy
Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
Endothelial Keratoplasty
Endovascular/Endoluminal Repair of Aortic Aneurysms
Enhanced External Counterpulsation (EECP) in the Outpatient Setting
Epidermal Growth Factor Receptor (EGFR) Testing for Non-Small Cell Lung Cancer (NSCLC)
Epiduroscopy
Exhaled Nitric Oxide and Breath Condensate pH Measurement for Respiratory Disorders
Extracorporeal Shock Wave Therapy for Orthopedic Conditions
 
 
F  
Facet Joint Allograft Implants for Facet Disease
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Fetal Surgery for Prenatally Diagnosed Malformations
Fluocinolone Acetonide Intravitreal Implant
Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
Functional Magnetic Resonance Imaging (fMRI)
 
 
G  
Gastric Electrical Stimulation
Gene Expression Profiling for Managing Breast Cancer Treatment
Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer’s Disease
Genetic Testing for Cancer Susceptibility
Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
Glucose Monitoring and Related Supplies
Growth Hormone
 
 
H  
Heart Transplantation
Heart/Lung Transplantation
Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
Hematopoietic Stem Cell Transplantation for Diabetes
Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Amyloidosis
Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
Hepatic Activation Therapy
High Intensity Focused Ultrasound (HIFU) for the Treatment of Prostate Cancer
High-Dose Chemotherapy with Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
Hip Resurfacing
Hippotherapy
Histamine Desensitization Therapy
Hyaluronan Binding Assay (HBA)
Hyaluronan Injections for Musculoskeletal Conditions in Joints Other Than the Knee
Hyperbaric Oxygen Therapy (Systemic/Topical)
Hyperoxemic Reperfusion Therapy
Hyperthermia for Cancer Therapy
 
 
I  
Idiopathic Environmental Illness (IEI)
Imaging Techniques for Screening and Identification of Cervical Cancer
Immune Cell Function Assay for the Management of Organ Transplant Rejection
Immunizations
Implantable Cardioverter-Defibrillator (ICD)
Implantable Infusion Pumps
Implanted Devices for Spinal Stenosis
Implanted Spinal Cord Stimulators (SCS)
In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
In Vivo Analysis of Colorectal Polyps
Inhaled Nitric Oxide for the Treatment of Respiratory Failure
Insulin Potentiation Therapy
Intensity Modulated Radiation Therapy (IMRT)
Intervertebral Stabilization Devices
Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty)
Intraepidermal Nerve Fiber Density Testing
Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
Intraocular Epiretinal Brachytherapy
Intraoperative Radiation Therapy
Intravascular Brachytherapy (Coronary and Non-Coronary)
Intravenous Immunoglobulin as a Treatment of Recurrent Spontaneous Abortion
Intravitreal and Periocular Injection Treatment for Retinal Vascular Conditions
Investigational Criteria
 
 
J  
Janus Kinase 2 (JAK2) V617F Gene Mutation Assay
 
K  
Keratoprosthesis
 
 
L  
Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
Laparoscopic and Percutaneous MRI-Image Guided Techniques for Myolysis as a Treatment of Uterine Fibroids
Liver Transplantation
Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
Low Field and Conventional Magnetic Resonance Imaging (MRI) for Screening, Diagnosing and Monitoring
Low-Frequency Ultrasound Therapy for Wound Management
Lung and Lobar Transplantation
Lung Volume Reduction Surgery
Lysis of Epidural Adhesions
 
 
M  
Magnetic Resonance Neurography
Magnetic Resonance Spectroscopy (MRS)
Magnetic Source Imaging and Magnetoencephalography
Mandibular/Maxillary (Orthognathic) Surgery
Manipulation Under Anesthesia of the Spine and Joints other than the Knee
Mastectomy for Gynecomastia
Mechanical Circulatory Assist Devices (Ventricular Assist Devices and Artificial Hearts)
Mechanical Embolectomy for Treatment of Acute Stroke
Mechanized Spinal Distraction Therapy for Low Back Pain (VAX-D® Therapy, DRS® System, Accu-Spina System™, IDD Therapy)
Medical Policy Formation
Medical Necessity Criteria
Melanoma Vaccines
Meniscal Allograft Transplantation of the Knee
Mesenchymal Stem Cell Therapy For Orthopedic Indications
Microprocessor Controlled Lower Limb Prosthesis
Microvolt T-Wave Alternans
MR Angiography (MRA) of the Spinal Canal
MRI Guided High Intensity Focused Ultrasound Ablation of Uterine Fibroids
MRI of the Bone Marrow
MRI of the Breast
 
 
N  
Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) (Including Radiofrequency Ablation of Nasal Turbinates for Nasal Obstruction with or without OSA)
Nasal Valve Suspension
Near-Infrared Imaging as an Aid for the Evaluation of Coronary Artery Plaques (LipiScan™ Coronary Imaging System)
Nerve Graft after Prostatectomy
Neural Therapy
Neutron Beam Radiotherapy
Niofeedback for Muscle Re-education and Chronic Pain
Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting
 
 
O  
Occipital Nerve Stimulation
Omalixumab (Xolair®) for Treatment of Asthma
Ophthalmologic Techniques for Evaluating Glaucoma
Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification
Oscillatory Devices for Airway Clearance including High Frequency Chest Compression (Vest™ Airway Clearance System) and Intrapulmonary Percussive Ventilation (IPV)
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
 
 
P  
Pancreas Transplantation and Pancreas Kidney Transplantation
Panitumumab (Vectibix™)
Panniculectomy and Abdominoplasty
Parenteral Antibiotics for the Treatment of Lyme Disease
Partial Left Ventriculectomy
Patient-Operated Spinal Unloading Devices
Percutaneous Neurolysis for Chronic Back Pain
Percutaneous Spinal Procedures (Vertebroplasty, Kyphoplasty and Sacroplasty)
Percutaneous and Endoscopic Spinal Surgery
Peripheral Bone Mineral Density Measurement
PET Scanning Using Gamma Cameras
Photocoagulation of Macular Drusen
Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
Positional MRI
Positron Emission Tomography (PET) and PET/CT Fusion
Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent
Predictive Genetic Testing for Non-Malignant Diseases
Preimplantation Genetic Diagnosis Testing
Presbyopia and Astigmatism-Correcting Intraocular Lenses
Prevention of Respiratory Syncytial Virus Infections
Preventive Health Guidelines
Prolotherapy/Sclerotherapy for Joint and Ligamentous Injections
Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension (epoprostenol [Flolan®], treprostinil [TYVASO™, Remodulin®], iloprost [Ventavis®])
Prostate Saturation Biopsy
Proton Beam Radiation Therapy
 
 
Q  
Quantitative Muscle Testing Devices
Quantitative Sensory Testing
 
 
R  
Radiofrequency Ablation as a Treatment for Barrett’s Esophagus
Radiofrequency Ablation for Trigeminal Neuralgia
Radiofrequency Ablation to Treat Tumors Outside the Liver
Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy
Real-Time Intra-Fraction Target Tracking During Radiation Therapy
Real-Time Remote Heart Monitors
Recombinant Human Bone Morphogenetic Protein
Reduction Mammaplasty
Refractive Surgery
Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
Rhinophototherapy
Rituximab (Rituxan®)
 
 
S  
Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors (i.e., SIR-Sphere and TheraSpheres)
Semi-Implantable Middle Ear Hearing Aids
Sensory Stimulation for Brain-Injured Patients in Coma or Vegetative State
Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications
Skin Contact Monochromatic Infrared Energy Therapy (MIRE)
Small Bowel and Multivisceral Transplant including Small Bowel/Liver
SPECT/CT Fusion Imaging
Standing Frames
Stereotactic Radiofrequency Pallidotomy
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT)
Stretching Devices for the Treatment of Joint Stiffness and Contracture
Subcutaneous Hormone Replacement Implants
Subtalar Arthroereisis
Suprachoroidal Injection of a Pharmacologic Agent
Surgery for Clinically Severe Obesity
Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
Surgical Treatment of Femoroacetabular Impingement Syndrome
Surgical Treatment of Migraine Headaches
 
 
T  
Techniques for the Measurement of Body Composition
Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
TempTouch® Dermal Thermometer
Tocilizumab (Actemra®)
Topographic Genotyping (PathFinderTG® Test)
Total Ankle Replacement
Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
Transanal Radiofrequency Treatment of Fecal Incontinence
Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation)
Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE)
Transcatheter Closure of Cardiac Defects
Transciliary Fistulization for the Treatment of Glaucoma
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Neuropsychiatric Disorders
Transendoscopic Therapy for Gastroesophageal Reflux Disease
Transmyocardial Revascularization
Transtympanic Micropressure for the Treatment of Ménière’s Disease `
Trastuzumab (Herceptin®)
Treatment for Obstructive Sleep Apnea in Adults
Treatment of Autism, Asperger’s Syndrome, Rett Syndrome, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (NOS)
Treatment of Hyperhidrosis
Treatment of Osteochondral Defects of the Knee and Ankle
Treatment of Tinnitus
Treatments for Urinary Incontinence and Urinary Retention
Treatment of Varicose Veins (Lower Extremities)
Tumor Necrosis Factor Antagonists
 
 
U  
Ultrafiltration in Decompensation Heart Failure
Ultrasound Bone Growth Stimulation
Ultrasound for the Evaluation of Paranasal Sinuses
Ultraviolet Light, including Laser Therapy, for the Treatment of Skin Disorders
Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
Unicondylar Interpositional Spacer
Use of 3-D and 4-D Ultrasound in Maternity Care
Ustekinumab (Stelara™)
 
 
V  
Vacuum Assisted Wound Therapy in the Outpatient Setting
Vagus Nerve Stimulation
Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
 
 
W  
Wearable Cardioverter Defibrillators
Whole Body CT Scanning
Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule
Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders (SmartPill GI Monitoring System®)
 
 
Z  
Ziconotide Intrathecal Infusion (Prialt®) for Severe Chronic Pain
 

® Anthem is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association © 2009 Anthem Blue Cross.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.