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Medical Policies

 

These documents are provided for informational purposes only and are not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied.  Benefits are determined by the subscriber certificate that is in effect at the time services are rendered. Medical practices and knowledge are constantly changing and we reserve the right to review and revise medical policies periodically and without notice.

 

Updated: 06/14/2010

 

Ambulance and Medical Transport Services Download PDF
Audiology - see "Evaluation of Hearing Impairment"
Autologous Chondrocyte Transplantation Download PDF

Bariatric Surgery for Morbid Obesity Download PDF

Blood Download PDF
Breast Pumps Download PDF
Capsule Endoscopy Download PDF
Cardiac Rehabilitation Download PDF
Chiropractic Services Download PDF
Continuous Glucose Monitoring (CGMS) Download PDF
Continuous Passive Motion (CPM) Device Download PDF
Cosmetic and Reconstructive Procedures Download PDF
Cranial/Scalp/Wig Prosthesis Download PDF
Dental Services Download PDF
Evaluation of Hearing Impairment (formerly: Audiology) Download PDF
External Insulin Pump Download PDF
Gastric Electrical Stimulation Download PDF
GYN Care Download PDF
Hip Resurfacing Download PDF
Home Infusion Download PDF
Hospital Beds Download PDF
Magnetic Resonance Imaging (MRI) of the Breast Download PDF
Medical Equipment and Supplies Durable Medical Equipment (DME) and Supplies Download PDF
Medical Equipment and Supplies Prosthetics and Orthotics Download PDF
Medical Nutrition for Inherited Metabolic Disease Download PDF
Monitored Anesthesia for EndoscopyDownload PDF
Nebulizers Download PDF
Neurodevelopmental Assessment & Neuropsychological Testing Download PDF
Neuromuscular Electrical Stimulator (NMES) Download PDF
Nutritional Counseling  Download PDF
Osteochondral Autograft Transfer System (OATS) Download PDF
Out-of-Network Services Download PDF
Oxygen Therapy Download PDF
Physical and Occupational Therapy - 2009 Download PDF
Private Duty Nursing Download PDF
Pulmonary Rehabilitation Download PDF
Radiology - All (CT, MRI, MRA, MRS and PET scans)
Sleep Disorders Diagnosis and Treatment Download PDF
Speech TherapyDownload PDF
Specialist Role in Managed Care Download PDF
Temporomandibular Joint Disorder (TMJ) Download PDF
TPN and EN Home Infusion Therapy Download PDF
Transcutaneous Electrical Nerve Stimulation (TENS) Download PDF
Transplants Download PDF
Vision Services Download PDF
Wheelchairs Download PDF