VERMONT Medical Policies
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Updated: 5/07/2013 |
| Adjustable Cranial Orthoses - Effective 4-16-12 |
| Ambulance and Medical Transport - Effective 4-16-12 |
| Array Comparative Genomic Hybridization (ACGH) - Effective 10-1-12 |
| Audiology - see "Evaluation of Hearing Impairment" |
| Autism Spectrum Disorder, Coverage of Services - Effective 10-1-12 |
| Autologous Chondrocyte Transplantation |
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Bariatric Surgery for Morbid Obesity
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| Bariatric Surgery for Morbid Obesity - Effective 7/1/13 |
| Blood and Blood Products |
| Cancer Antigen 125 (CA-125) Testing |
| Cardiac Imaging |
| Cardiac Rehabilitation |
| Chiropractic Services |
| Cochlear Implants and Aural Rehabilitation Therapy |
| Continuous or Intermittent Glucose Monitoring(CGMS) - Effective 4-16-12 |
| Continuous Passive Motion (CPM) in the Home |
| Cosmetic and Reconstructive Procedures |
| Cranial/Scalp/Wig Prosthesis - Effective 6-1-13 |
| Cranial/Scalp/Wig Prosthesis |
| Dental Services |
| Drug Wastage |
| Early Childhood Developmental Disorders - Effective 10-1-12 |
| Enteral Nutrition |
| Evaluation of Hearing Impairment - Effective 5-16-12 |
| External Insulin Pump - Effective 4-16-12 |
| Gastric Electrical Stimulators |
| Gender Reassignment Surgery - Effective 12-1-12 |
| GYN Care - Effective 12-1-12 |
| Hip Resurfacing - Effective 6-1-13 |
| Hip Resurfacing |
| Hippotherapy and Recreational Therapy - Effective 10-1-12 |
| Home Infusion |
Homocysteine Testing in the Screening, Diagnosis, and Management of
Cardiovascular Disease |
| Hospital Beds |
| Hospital Grade Electric Breast Pumps |
| Medical Equipment and Supplies Durable Medical Equipment (DME) and Supplies |
| Medical Equipment and Supplies Prosthetics and Orthotics |
| Medical Nutrition for Inherited Metabolic Disease |
| Monitored Anesthesia for Endoscopy - Effective 12-1-12 |
| Nebulizers |
| Negative Pressure Wound Therapy |
| Neuromuscular Electrical Stimulator (NMES) - Effective 5-1-13 |
| Neuromuscular Electrical Stimulator (NMES) |
| Neuropsychological Testing - Effective 10-1-12 |
| Nutritional Counseling |
| Occipital Nerve Stimulation |
| Occupational Therapy - Effective 10-1-12 |
| Oral Appliances for Obstructive Sleep Apnea - Effective 4-16-12 |
| Osteochondral Autograft Transfer System (OATS) |
| Out-of-Network Services |
| Oxygen Therapy & Supplies - Effective 6-01-12 |
| Pediatric Neurodevelpmental and Autism Screening - Effective 10-1-12 |
| Physical Therapy - Effective 10-1-12 |
| Posterior Tibial Nerve Stimulation for Voiding Dysfunction - Effective 01-01-12 |
| Private Duty Nursing |
| Pulmonary Rehabilitation |
| Radiology - Cardiac Related Imaging |
| Radiology - All other Non-Cardiac Imaging |
| Sleep Disorders & Treatment - Effective 6-1-13 |
| Sleep Disorders Diagnosis and Treatment |
| Speech Therapy - Effective 10-1-12 |
| Specialist Role in Managed Care |
| Temporomandibular Joint Disease - Effective 6-01-12 |
| Total Parenteral Nutrition - Effective 4-16-12 |
| Transcutaneous Electrical Nerve Stimulation (TENS) - Effective 5-16-12 |
| Transplants |
| Treatment of Varicose Veins/Venous Insufficiency |
| Vision Services |
| Wheelchairs |
| Wireless Capsule Endoscopy - Effective 4-16-12 |
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