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Behavioral Health Management

Our Behaviorial Health Management Department focuses on improving the quality of life for people suffering from mental health or substance abuse issues (MHSA) and is a key aspect of a person’s overall health and wellbeing. Learn More >>>

Mental Health Parity

The Mental Health Parity Act is effective October 3, 2009. Click here to learn more about the Act and how it affects you. Learn More >>>

Recent Medical Policy Updates

Changes made reflected in Issue 10:2009

Policy Number	Policy Title	Comments
1.01.23	Transtympanic Micropressure Applications as a Treatment of Meniere`s Disease	investigational
1.01.24	Interferential Stimulation for Treatment of Pain	*investigational*
1.01.27	Electrical Stimulation for the Treatment of Arthritis	*investigational*
2.01.02	Dynamic Posturography	*not medically necessary*
2.01.35	Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain	*investigational*
2.01.57	Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds	*investigational*
2.01.59	Ultrasonographic Evaluation of Skin Lesions	*not medically necessary/ investigational*
2.01.79	Non-Contact Ultrasound Treatment for Wounds	*investigational*
2.02.10	Biventricular Pacemaksers for the Treatment of Congestive Heart Failure	*medically necessary/ investigational*
2.03.10	Real-Time Intra-Fraction Target Tracking during Radiation Therapy	*not medically necessary*
2.04.08	Genetic Testing for Inherited Susceptibility to Colon Cancer; Including Microsatellite Instability Testing	*medically necessary/ not medically necessary*
3.01.99*	Mental Health and Substance Abuse (MHSA) Coverage Guidelines	N/A
4.01.16	Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies	*medically necessary/ investigational*
5.01.10	Immune Prophylaxis for Respiratory Syncytial Virus	*medically necessary/ not medically necessary/ investigational*
5.01.17	Repository Corticotropin Injection	*medically necessary/ investigational*
5.01.18*	Bevacizumab in Advanced Adenocarcinoma of the Pancreas	*investigational*
6.01.30	Screening for Lung Cancer Using CT Scanning or Chest Radiographs	*investigational*
7.01.15	Meniscal Allografts and Collagen Meniscus Implants	*medically necessary/ investigational*
7.01.19	Periurethral Bulking Agents for the Treatment of Incontinence	*medically necessary/ investigational*
7.01.87	Artificial Intervertebral Disc: Lumbar Spine	*investigational*
7.01.98	Minimally Invasive Hip and Total Knee Arthroplasty	*medically necessary*
7.01.102	Periurethral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)	*medically necessary/ investigational*
7.01.106	Posterior Tibial Nerve Stimulation for Voiding Dysfunction	investigational
7.01.112	Transanal Endoscopic Microsurgery (TEMS)	*medically necessary/ investigational*
7.01.121*	Saturation Biopsy for Diagnosis and Staging of Prostate Cancer	*investigational*
8.01.08	Intraoperative Radiation Therapy	*medically necessary/ investigational*
8.01.44	Intradialytic Parenteral Nutrition	*medically necessary/ not medically necessary/ investigational*
8.03.01	Functional Neuromuscular Electrical Stimulation	*investigational*
8.03.09	Vertebral Axial Decompression	*investigational*
8.03.11	Endobronchial Brachytherapy	*medically necessary/ investigational*
8.03.13	Sensory Integration Therapy	*investigational*
9.03.15	Retinal Prosthesis	*investigational*
9.03.19	Suprachoroidal Delivery of Pharmacological Agents	*investigational*
Lumbar Fusion Guidelines	Cervical guidelines added
These policies were 'archived' and are no longer in use	2.01.15 - Intravenous or Subcutaneous Histamine Therapy 2.01.25 - Erectile Dysfunction 2.01.32 - Ketogenic Diet as a Treatment of Refractory Epilepsy 4.01.01 - Fetal Echocardiography 4.01.02 - Prenatal Genetic & Chromosomal Metabolic Testing 4.01.08 - External Cephalic Version 4.02.03 - Birth Control 5.01.02 - Nicotine Replacement 5.01.03 - Colony-Stimulating Factors 6.01.09 - Vacuum-Assisted Breast Biopsy 6.01.11 - Herniography 6.01.19 - Intracoronary Doppler Ultrasound 6.01.28 - Transrectal Ultrasound for Staging Rectal Cancer 7.01.06 - Disposable Arthroscopy 7.01.11 - Ilizarov Bone Lengthening Procedure 7.01.23 - Tissue Pressure Measurement 7.01.24 - Vitrectomy 7.01.28 - Selective Posterior Rhizotomy for the Spasticity of Cerebral Palsy 7.01.31 - Continent Ileostomy and Urostomy 7.01.32 - Chemonucleolysis 7.01.33 - Posterior Capsulotomy 7.01.36 - Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae 7.01.53 - Transjugular Intrahepatic Portosystemic Shunt (TIPS) 7.01.64 - Ross Pulmonary Autograft 7.01.70 - Free Vascularized Fibular Grafting for Treatment of Osteonecrosis of the Hip
These policies have been re-numbered:	5.01.17 Specialty Drugs renumbered to 5.01.93 5.01.18 Tysabri (natalizumab) renumbered to 5.01.97 5.01.19 Generic Initiative Medications renumbered to 5.01.96 5.01.20 Xolair (Omalizumab) renumbered to 5.01.95 5.01.22 ACH Gel (Adrenocorticotropin Hormone) renumbered to 5.01.94

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