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| Last Updated: April 3, 2006 |
Benefit Policy Index
Below is a list of our policies and procedures related to benefits.
If you would a copy of a particular policy, please contact our
Customer Call Center at (800) 852-9780.
| -A- |
| Policy |
Category |
Policy Number |
|
Accounting For Visits - Behavioral Health
|
Administrative/Misc.
|
AM-10
|
|
Acupuncture
|
Specialty
|
SP-26
|
|
Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy
|
Specialty
|
SP-39
|
|
Alcohol Abuse Services
|
Ancillary Services
|
AS-18
|
|
Amevive
|
Prescription/Medications
|
PM-5
|
|
Amniocentesis & Chorionic Villus Sampling
|
Diagnostic
|
DIAG-3
|
|
Ambulance - Ground, Air, Water
|
Ancillary Services
|
AS-4
|
|
Anesthesia/Sedation - Oral Surgery
|
Specialty
|
SP-16
|
|
Artificial Heart, VAD
|
Medical/Surgical
|
MS-23
|
|
Arthritis (Rheumatoid) Remicade for Treatment
|
Prescription/Medications
|
PM-8
|
|
Asthma Education (Health Management Education)
|
Ancillary Services
|
AS-10
|
|
Attention Deficit Hyperactivity Disorder (Children & Adults)
|
Specialty
|
SP-17
|
|
Autism & Developmental Delay
|
Specialty
|
SP-20
|
[Top]
| -B- |
| Policy |
Category |
Policy Number |
|
BAK/TIF
|
Medical/Surgical
|
MS-9
|
|
Bariatric Surgery
|
Medical/Surgical
|
MS-10
|
|
Behavioral Health – Accounting for Visits
|
Admin. & Misc
|
AM-10
|
|
Benefit Determination & Interpretation Process
|
Admin. & Misc
|
AM-7
|
|
Biofeedback
|
Specialty
|
SP-10
|
|
Blepharoplasty
|
Medical/Surgical
|
MS-16
|
|
Blood Donation
|
Specialty
|
SP-13
|
|
Blood Glucose Meters & Related Supplies
|
DME & Related
|
DME-8
|
|
Bone Growth Stimulator
|
DME & Related
|
DME-15
|
|
Bone Marrow Transplant (BMT) and
Peripheral Stem Cell Transplant (PSCT)
|
Medical/Surgical
|
MS-8
|
|
Botulinum Toxin (Botox, Myobloc)
|
Prescription/Medications
|
PM-2
|
|
Bowel Implantation
|
Medical/Surgical
|
MS-5
|
|
Brachytherapy, Intravascular (Coronary)
|
Specialty
|
SP-11
|
|
Brain Stimulation, Deep
|
Medical/Surgical
|
MS-29
|
|
Breast Cancer Screening
|
Diagnostic
|
DIAG-1
|
|
Breast Implant Removal
|
Medical/Surgical
|
MS-11
|
|
Breast Reconstructive Surgery
|
Medical/Surgical
|
MS-6
|
|
Breast Reduction Mammoplasty
|
Medical/Surgical
|
MS-1
|
[Top]
| -C- |
| Policy |
Category |
Policy Number |
|
Capsule Endoscopy
|
Diagnostic
|
DIAG-12
|
|
Cardiac Defibrillator (ICD)
|
Medical Surgical
|
MS-2
|
|
Cardiac Rehabilitation
|
Ancillary Services
|
AS-1
|
|
Cardiomyopathy, Alcohol Septal Ablation
|
Specialty
|
SP-39
|
|
CardioNet
|
Diagnostic
|
DIAG-9
|
|
Chiropractic Services
|
Specialty
|
SP-30
|
|
Chorionic Villus Sampling & Amniocentesis
|
Diagnostic
|
DIAG-3
|
|
Clinical Trials
|
Administrative & Misc.
|
AM-1
|
|
Cochlear Implantation
|
Medical/Surgical
|
MS-28
|
|
Compression Pumps/Complex Lymphedema Therapy
|
Specialty
|
SP-40
|
|
Corneal Topography
|
Diagnostic
|
DIAG-10
|
|
Cosmetic Surgery
|
Medical/Surgical
|
MS-13
|
|
Counseling, Family Planning
|
Specialty
|
SP-4
|
|
Counseling, Genetic
|
Specialty
|
SP-22
|
|
Counseling, Nutritional
|
Ancillary Services
|
AS-2
|
|
Court Ordered Services/Third Party Requests
|
Administrative & Misc.
|
AM-9
|
|
Crohn’s Disease (Remicade for Treatment)
|
Prescription/Medications
|
PM-7
|
[Top]
| -D- |
| Policy |
Category |
Policy Number |
|
Deep Brain Stimulation
|
Medical/Surgical
|
MS-29
|
|
Defibrillator, ICD
|
Medical Surgical
|
MS-2
|
|
Depo-Provera
|
Prescription/Medications
|
PM-1
|
|
Developmental Delay & Autism
|
Ancillary Services
|
SP-20
|
|
Donor Issues, Transplant
|
Administrative & Misc.
|
AM-2
|
|
Drug Abuse Services
|
Ancillary Services
|
AS-18
|
|
Drug Use, Off-Label
|
Prescription/Medications
|
PM-4
|
|
Ductal Lavage
|
|
DIAG-4
|
|
Durable Medical Equipment:
Prosthetics & Orthotics-General Statement of Policy
|
DME & Related
|
DME-4
|
[Top]
| -E- |
| Policy |
Category |
Policy Number |
|
Ear Plugs/Ear Molds
|
DME & Related
|
DME-1
|
|
Embolization, Uterine Artery
|
Medical/Surgical
|
MS-15
|
|
Emergency Medical Care/Urgent Care
|
Ancillary Services
|
AS-6
|
|
End Stage Renal Disease (ESRD)
|
Administrative & Misc.
|
AM-11
|
|
Endometrial Ablation Procedures for Menorrhagia
|
Medical/Surgical
|
MS-20
|
|
Endoscopy, Capsule
|
Diagnostic
|
DIAG-12
|
|
Event Monitoring
|
Diagnostic
|
DIAG-9
|
|
Experimental & Investigational Determinations
|
Administrative & Misc.
|
AM-8
|
|
Extracorporeal Shock Wave Therapy for Musculoskeletal
Conditions
|
Specialty
|
SP-15
|
|
Eye Exam/Vision Care
|
Specialty
|
SP-12
|
[Top]
| -F- |
| Policy |
Category |
Policy Number |
|
Foot Care/Podiatric Services
|
Specialty
|
SP-9
|
|
Foot Orthotics
|
DME & Related
|
DME-3
|
|
Functional Assessment
|
Specialty
|
SP-14
|
|
Fusion Procedures
|
Medical/Surgical
|
MS-9
|
[Top]
| -G- |
| Policy |
Category |
Policy Number |
|
Gastric Surgery for Clinically Severe Obesity
|
Medical/Surgical
|
MS-10
|
|
Genetic Counseling/Genetic Testing/Genetic Screening
|
Specialty
|
SP-22
|
|
Glucose Meters & Related Supplies
|
DME & Related
|
DME-8
|
|
Gynecomastia Surgery
|
Medical/Surgical
|
MS-12
|
[Top]
| -H- |
| Policy |
Category |
Policy Number |
|
Hearing Aids
|
DME & Related
|
DME-6
|
|
Heart Transplantation - Adult
|
Medical/Surgical
|
MS-34
|
|
Heart Transplantation - Pediatric
|
Medical/Surgical
|
MS-35
|
|
Heart-Lung-Liver Transplantation
|
Medical/Surgical
|
MS-36
|
|
Heart-Lung Transplantation
|
Medical/Surgical
|
MS-33
|
|
Holter Monitoring
|
Diagnostic
|
DIAG-9
|
|
Home Health Care
|
Ancillary Services
|
AS-7
|
|
Hospice
|
Ancillary Services
|
AS-15
|
|
Hyalgan (Sodium Hyaluronate)
|
Prescription/Medications
|
PM-6
|
[Top]
| -I- |
| Policy |
Category |
Policy Number |
|
Immunization – Vaccinations, Inoculations
|
Prescription/Medications
|
PM-11
|
|
Implant Removal, Breast
|
Medical/Surgical
|
MS-11
|
|
Implantable Cardioverter Defibrillator (ICD)
|
Medical/Surgical
|
MS-2
|
|
Implantable Sacral Nerve Stimulation for Urinary Incontinence
|
Medical/Surgical
|
SP-32
|
|
Impotence
|
Specialty
|
SP-6
|
|
Infertility & Related Reproductive Issues – Diagnosis & Limited
Treatment
|
Specialty
|
SP-5
|
|
Infliximab (Remicade for Crohn’s Disease)
|
Prescription/Medications
|
PM-7
|
|
Injectable Drug Coverage
|
Prescription/Medications
|
PM-17
|
|
Insulin Delivery Devices
|
DME & Related
|
DME-9
|
|
Intradiscal Electrothermal Therapy
|
Medical/Surgical
|
MS-24
|
|
Intravascular Brachytherapy (Coronary)
|
Specialty
|
SP-11
|
|
Investigational & Experimental Determinations
|
Administrative & Misc.
|
AM-8
|
[Top]
| -J, K- |
| Policy |
Category |
Policy Number |
|
Keratoplasty, Refractive
|
Medical/Surgical
|
MS-3
|
|
Kidney Transplantation
|
Medical/Surgical
|
MS-39
|
|
Kyphoplasty
|
Medical/Surgical
|
MS-41
|
[Top]
| -L- |
| Policy |
Category |
Policy Number |
|
Laser Treatment for Port Wine Stains
|
Specialty
|
SP-25
|
|
LASIK Surgery
|
Specialty
|
MS-3
|
|
Lavage, Ductal
|
Diagnostic
|
DIAG-4
|
|
Liver Transplantation
|
Medical/Surgical
|
MS-38
|
|
Lung Transplantation
|
Medical/Surgical
|
MS-37
|
|
Lymphedema Therapy/Compression Pumps
|
Specialty
|
SP-40
|
[Top]
| -M- |
| Policy |
Category |
Policy Number |
|
Mammography Screening
|
Diagnostic
|
DIAG-1
|
|
Mammoplasty, Reduction
|
Medical/Surgical
|
MS-1
|
|
Meniscal Allograft
|
Medical/Surgical
|
MS-26
|
|
Mental Health Therapy
|
Specialty
|
SP-18
|
|
Mental Health/Substance Abuse Accounting for Visits
|
Administrative & Misc.
|
AM-10
|
|
Microvolt T-Wave Alternans
|
Diagnostic
|
DIAG-5
|
|
Mobile Cardiac Outpatient Telemetry (CardioNet)
|
Medical/Surgical
|
DIAG-9
|
|
Multivisceral Transplantation
|
Medical/Surgical
|
MS-5
|
[Top]
| -N- |
| Policy |
Category |
Policy Number |
|
Neuropsychological/Psychological Testing
|
Diagnostic
|
DIAG-8
|
|
Neurotization of Brachial Plexus
|
Medical/Surgical
|
MS-19
|
|
Nutritional Counseling
|
Ancillary Services
|
AS-2
|
|
Nutritional Therapies
|
DME & Related
|
DME-13
|
[Top]
| -O- |
| Policy |
Category |
Policy Number |
|
Obesity Surgery
|
Medical/Surgical
|
MS-10
|
|
Obstructive Sleep Apnea Treatment
|
Medical/Surgical
|
MS-17
|
|
Occupational Therapy/Physical Therapy
|
Ancillary Services
|
AS-12
|
|
Ocular Photodynamic Therapy with Verteporfin
|
Specialty
|
SP-42
|
|
Ocular Prothesis (Vision Care/Eye Exam)
|
Specialty
|
SP-12
|
|
Off-Label Drug Use
|
Prescription/Medications
|
PM-4
|
|
Omalizumab/Xolair
|
Prescription/Medications
|
PM-3
|
|
Oral Surgery
|
Specialty
|
SP-2
|
|
Oral Surgery – Anesthesia/Sedation
|
Specialty
|
SP-16
|
|
Orthognathic Surgery
|
Medical/Surgery
|
MS-31
|
|
Orthopedic Footwear
|
DME & Related
|
DME-3
|
|
Osteochondral Replacement Procedures
|
Medical/Surgical
|
MS-27
|
|
Outpatient Nutritional Support
|
DME & Related
|
DME-13
|
[Top]
| -P- |
| Policy |
Category |
Policy Number |
|
Palivizumab/Synagis
|
Prescription/Medications
|
PM-9
|
|
Pancreas Transplantation
|
Medical/Surgical
|
MS-40
|
|
Panniculectomy
|
Medical/Surgical
|
MS-32
|
|
Penile Erection Pump
|
Specialty
|
SP-6
|
|
Penile Prothesis
|
Speciality
|
SP-6
|
|
Peripheral Stem Cell Transplant/Bone Marrow Transplant
|
Medical/Surgical
|
MS-8
|
|
Percutaneous Vertebroplasty
|
Medical/Surgical
|
MS-30
|
|
PET Scans
|
Diagnostic
|
DIAG-11
|
|
Photodynamic Therapy with Verteporfin
|
Specialty
|
SP-42
|
|
Physical Rehabilitation
|
Ancillary Services
|
AS-17
|
|
Physical Therapy/Occupational Therapy
|
Specialty
|
AS-12
|
|
Plantar Fasciitis, Extracorporeal Shock Wave Treatment
|
Specialty
|
SP-15
|
|
Podiatric Services/Routine Foot Care
|
Specialty
|
SP-9
|
|
Port Wine Stains
|
Specialty
|
SP-25
|
|
Prophylactic Mastectomy
|
Medical/Surgical
|
MS-7
|
|
Psoriasis, Amevive
|
Prescription/Medications
|
PM-5
|
|
Psychological/Neuropsychological Testing
|
Diagnostic
|
DIAG-8
|
|
Pulmonary Rehabilitation
|
Ancillary Services
|
AS-14
|
[Top]
| -R- |
| Policy |
Category |
Policy Number |
|
Radiofrequency Ablation for Back Pain
|
Specialty
|
SP-43
|
|
Reduction Mammoplasty
|
Medical/Surgical
|
MS-1
|
|
Refractive Keratoplasty
|
Medical/Surgical
|
MS-3
|
|
Rehabilitation (Cardiac)
|
Ancillary Services
|
AS-1
|
|
Rehabilitation (Physical)
|
Ancillary Services
|
AS-17
|
|
Rehabilitation (Pulmonary)
|
Ancillary Services
|
AS-14
|
|
Remicade for Crohn’s Disease
|
Prescription/Medications
|
PM-7
|
|
Remicade for Rheumatoid Arthritis
|
Prescription/Medications
|
PM-8
|
|
RespiGam/RSV-IGIV
|
Prescription/Medications
|
PM-9
|
|
Retinal Screening (Diabetic) DigiScope
|
Diagnostic
|
DIAG-13
|
|
Revascularization, Transmyocardial
|
Medical/Surgical
|
MS-22
|
|
Rhinoplasty
|
Medical/Surgical
|
MS-14
|
|
RK Surgery
|
Medical/Surgical
|
MS-3
|
[Top]
| -S- |
| Policy |
Category |
Policy Number |
|
Sacral Nerve Stimulation for Urinary Incontinence, Implantable
|
Specialty
|
SP-32
|
|
Scans, PET
|
Diagnostic`
|
DIAG-11
|
|
Sclerotherapy for Varicose Veins of the Lower Extremities
|
Medical/Surgical
|
MS-18
|
|
Sedation/Anesthesia (Surgical, Diagnostic, Oral Surgery)
|
Specialty
|
SP-16
|
|
Sexual Dysfunction
|
Specialty
|
SP-6
|
|
Shock Wave Treatment for Chronic Plantar Fasciitis
|
Specialty
|
SP-15
|
|
Silicone Breast Implant Removal
|
Medical/Surgical
|
MS-11
|
|
Skilled Nursing Facilities
|
Ancillary Services
|
AS-8
|
|
Sleep Apnea, Treatment of Obstructive
|
Medical/Surgical
|
MS-17
|
|
Small Bowel, Small Bowel-Liver and Multivisceral Transplantation
|
Medical/Surgical
|
MS-5
|
|
Sodium Hyaluronate (Hyalgan, Supartz, Synvisc)
|
Prescription/Medications
|
PM-6
|
|
Somnoplasty (Obstructive Sleep Apnea Treatment)
|
Medical/Surgical
|
MS-17
|
|
Speech Therapy
|
Ancillary Services
|
AS-13
|
|
Spinal Cord Stimulation for Pain Management
|
Medical/Surgical
|
MS-21
|
|
Stimulation, Deep Brain
|
Medical/Surgical
|
MS-29
|
|
Substance Abuse/Mental Health, Accounting for Visits
|
Administrative & Misc.
|
AM-10
|
|
Sudden Cardiac Death, T-Wave Alternans
|
Diagnostic
|
DIAG-5
|
|
Supartz, Synvisc (Sodium Hyaluronate)
|
Prescription/Medications
|
PM-6
|
|
Synagis/Palivizumab
|
Prescription/Medications
|
PM-9
|
[Top]
| -T- |
| Policy |
Category |
Policy Number |
|
T-Wave Alternans
|
Diagnostic
|
DIAG-5
|
|
Temporomandibular Disorders
|
Specialty
|
SP-1
|
|
Termination of Coverage
|
Administrative & Misc.
|
AM-3
|
|
Termination of Pregnancy Family Planning Counseling
|
Specialty
|
SP-4
|
|
Third Party Requests/Court Ordered Services
|
Administrative & Misc.
|
AM-9
|
|
Transcatheter Closure for Septal Defects (MS-42)
|
Medical/Surgical
|
MS-42
|
|
Transmyocardial Revascularization
|
Medical/Surgical
|
MS-22
|
|
Transplants
|
Medical/Surgical
|
MS-4
(Retired 5/5/04)
|
|
Transplant – Donor Issues
|
Administrative & Misc.
|
AM-2
|
|
Transplant – Heart Lung
|
Medical/Surgical
|
MS-33
|
|
Transplant – Heart Transplantation – Adult
|
Medical/Surgical
|
MS-34
|
|
Transplant – Heart Transplantation – Pediatric
|
Medical/Surgical
|
MS-35
|
|
Transplant – Lung-Liver Transplantation
|
Medical/Surgical
|
MS-36
|
|
Transplant – Lung Transplantation
|
Medical/Surgical
|
MS-37
|
|
Transplant – Liver Transplantation
|
Medical/Surgical
|
MS-38
|
|
Transplant – Kidney Transplantation
|
Medical/Surgical
|
MS-39
|
|
Transplant – Pancreas Transplantation
|
Medical/Surgical
|
MS-40
|
|
Transplant – Small Bowel, Small Bowel-Liver & Multivisceral
Transplantation
|
Medical/Surgical
|
MS-5
|
[Top]
| -U- |
| Policy |
Category |
Policy Number |
|
Urgent Care/Emergency Medical Care
|
Ancillary Services
|
AS-6
|
|
Urinary Incontinence, Implantable Sacral Nerve Stimulation
for
|
Specialty
|
SP-32
|
|
Uterine Artery Embolization
|
Medical/Surgical
|
MS-15
|
|
Uvulopalatopharynoplasty-UPPP (Obstructive Sleep Apnea
Treatment)
|
Medical/Surgical
|
MS-17
|
[Top]
| -V- |
| Policy |
Category |
Policy Number |
|
Vacuum Erection Device
|
Specialty
|
SP-6
|
|
Varicose Veins, Sclerotherapy
|
Medical/Surgical
|
MS-18
|
|
Vision Care/Eye Exam
|
Specialty
|
SP-12
|
|
Ventricular Assist Device
|
Medical/Surgical
|
MS-23
|
|
Vertebroplasty, Percutaneous
|
Medical/Surgical
|
MS-30
|
|
Virtual Colonoscopy
|
Diagnostic
|
DIAG-2
|
[Top]
| -W- |
| Policy |
Category |
Policy Number |
|
Weight Loss Programs
|
Ancillary Services
|
AS-3
|
[Top]
| -X- |
| Policy |
Category |
Policy Number |
|
Xolair/Omalizumab
|
Prescription/Medications
|
PM-3
|
[Top] |
|
|
Providers