In this section you will find current versions of Medica coverage policies. A coverage policy communicates decisions about coverage and benefits for various medical services. Each coverage policy contains a description of the medical service, as well as the coverage determination, product application, coding considerations and requirements for prior authorization. Documents are updated as necessary.
For medical services that require prior authorization, please see the utilization management (UM) policies page under Provider Resources/Medical Policies.
To open and print Portable Document Format (.pdf) files you will need the computer application Adobe Acrobat Reader. If you do not have Acrobat Reader, you can download it here.
Important information – please read the Medical Policy Usage Notice before using these policies:
Medical Policy Usage Notice
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Inactivated Policies
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Acellular Allografts for Surgical Applications |
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Actigraphy |
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Ambulatory Blood Pressure Monitoring |
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Amino Acid-Based Elemental Oral Formulas |
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Antigen Leukocyte Cellular Antibody Test (ALCAT Test) for Food & Chemical Allergies |
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Artificial Intervertebral Disc Replacement |
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Auditory Integration Training (AIT) |
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Autologous Blood-Derived Products for Chronic Non-Healing Wounds |
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Autologous Chondrocyte Transplantation (ACT) for the Knee |
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Automated, Non-Invasive Nerve Conduction Testing: NC-Stat® |
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Bevacizumab (Avastin®) |
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Biventricular Pacing (Cardiac Resyncronization Therapy) for Heart Failure |
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Bladder Cancer Screening, Diagnosis and Monitoring Using Ancillary Urinary Tests |
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Blood Coagulation Home Testing Devices |
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Bone Anchored Hearing Aid (BAHA) |
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Botulinum Toxin (BTX) Treatment for Non-Cosmetic Indications |
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Breast Ductal Lavage |
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Breast Magnetic Resonance Imaging (MRI) |
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Breast Pumps |
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Cervicography |
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Chelation Therapy |
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Chemiluminescent Testing (ViziLite®) for Oral Cancer Screening |
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Chemoembolization for Hepatic Tumors |
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Cleft Lip and Palate - Tooth Extractions and Dental Implants |
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Computerized Dynamic Posturography |
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Continuous Glucose Monitoring |
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Cranial Electrotherapy Stimulation (CES) |
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Cytochrome P450 (CYP450) Genotyping |
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Cytotoxic Testing for Allergy Diagnosis |
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Darbepoetin alfa (Aranesp®) and Epoetin alfa (Epogen®, Procrit®) |
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Deep Brain Stimulation |
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Dietitian Consultations |
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Dynamic Stabilization Devices for Chronic Back Pain |
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Electrical or Electromagnetic Stimulation for Healing of Chronic Wounds |
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Electromagnetic Navigation Bronchoscopy Systems |
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Electrothermal Therapy for Treatment of Joint Instability or Laxity of Ligaments |
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Endoscopic Balloon Sinuplasty for Treatment of Chronic Sinusitis |
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Endoscopic Procedures for Treatment of Gastroesophageal Reflux Disease (GERD) |
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Epidural Lysis of Adhesions |
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Essure® Micro-Insert System |
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E-visits |
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Exhaled Breath Tests for Asthma and Other Inflammatory Pulmonary Conditions: Exhaled Nitric Oxide Breath Test and Exhaled Breath Condensate pH Measurement |
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External Counterpulsation (ECP) |
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Extracorporeal Magnetic Stimulation (EMS) for the Treatment of Urinary Incontinence |
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Extracorporeal Photopheresis (Photochemotherapy) |
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Extracorporeal Shock Wave Treatment for Musculoskeletal Indications |
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Eye Movement Desensitization and Reprocessing |
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Fast ForWordTM Speech Therapy Software |
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Fecal/Stool DNA (sDNA) Testing for Colorectal Cancer Screening and Monitoring |
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Fetal Fibronectin Testing |
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Functional Magnetic Resonance Imaging (fMRI) |
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Gastric Electrical Stimulation |
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Gastrointestinal Monitoring System (SmartPill) |
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Gene Expression Profiling for Prediction of Breast Cancer Recurrence |
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Genetic Assay for Warfarin Response |
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Genetic Testing |
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Genetic Testing for Prostate Cancer |
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Gynecomastia Surgery |
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Hair Analysis in the Clinical Setting |
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Health Research Institute/Pfeiffer Treatment Center Protocols |
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Helical Computed Tomography (CT) for Lung Cancer Screening |
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Herpes Zoster Vaccine (Zostavax®) |
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High Intensity Focused Ultrasound (HIFU) Therapy for Uterine Fibroids |
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Hip Resurfacing Arthroplasty |
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Home Sleep Studies for Diagnosis of Obstructive Sleep Apnea / Hypopnea Syndrome (OSAHS) |
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Home Use of Bilevel Positive Airway Pressure (Bilevel PAP) |
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Home Use of Continuous Positive Airway Pressure (CPAP) |
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Human Cell Derived Skin Substitutes for Chronic Wound Healing |
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Human Papillomavirus (HPV) Vaccine |
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Hyperbaric Oxygen Chamber Therapy (HBOT) |
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Immune Globulin Therapy (Intravenous and Subcutaneous) |
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Implanted Spinal Cord Stimulation for Chronic Intractable Pain |
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Infliximab (Remicade®) |
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Injury to a Pierced Body Part - Indications for Repair |
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Insulin Potentiation Therapy |
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Interferential Current Stimulation |
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Intra-articular Hyaluronan Therapy (Viscosupplementation) |
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Intracellular Nutrient Analysis: MicroNutrient Testing; Intracellular Mineral Electrolyte Analysis |
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Intracoronary Autologous Cell Transplantation for Cardiac Disease |
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Intradiscal Electrothermal Therapy (IDET) |
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Intravitreal Vascular Endothelial Growth Factor (VEGF) Inhibitor Antibody Treatment for Neovascular Ocular Indications |
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In Vitro Chemosensitivity and Chemoresistance Assays |
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Iontophoresis for Hyperhidrosis |
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Keratoprosthesis for Corneal Opacity |
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KRAS Mutation Analysis for Predicting Response to Drug Therapy |
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Laboratory Tests |
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Laser Surgery for Corneal Pathology |
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Laser Therapy for Smoking Cessation |
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Laser Treatments for Neovascularization Associated with Macular Degeneration |
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Leuprolide Acetate - Depot and Implant (Lupron Depot®, Lupron Depot-Ped®, Eligard®, Viadur®) |
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Light Treatment for Dermatologic Conditions |
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Lipoprotein-associated Phospholipase A2 (Lp-PLA2) Immunoassay for Prediction of Risk for Coronary Heart Disease or Ischemic Stroke (PLAC® Test) |
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Lovaas Therapy/Intensive Early Intervention Behavior Therapy Services (IEIBTS)/Intensive Behavior Intervention (IBI) |
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LTX3000TM (Spinal Unloading Device for Treatment of Low Back Pain) |
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Magnetic Resonance (MR) Coronary Angiography |
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Magnetic Resonance Spectroscopy (MRS) |
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Magnetoencephalography and Magnetic Source Imaging |
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Mechanized Spinal Decompression Traction Tables for Low Back Pain |
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MeniettTM Portable Pulse Generator for Treatment of Meniere's Disease |
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Minimally Invasive Spinal Fusion Surgery Using Axial Lumbar Interbody Fusion (AxiaLIF) or eXtreme Lateral Interbody Fusion (XLIF) |
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Multichannel Intraluminal Esophageal Impedance and pH Monitoring |
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Nebulized Intranasal Antibiotics/Antifungals |
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Neutralizing Antibody Tests in the Management of Multiple Sclerosis |
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Noncontact, Low-frequency Ultrasound Therapy for Healing of Chronic Wounds (MIST Therapy System™) |
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Noncontact Normothermic Wound Therapy |
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Non-Invasive Measurement of Left Ventricular End Diastolic Pressure |
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Nuclear Magnetic Resonance-determined Lipoprotein Subclass Test (LipoProfile®) |
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OncoSorb® Therapy (UltraPheresis) for Non-Hematologic Cancer |
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Orthognathic Surgery |
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OrthotracTM Pneumatic Vest (Spinal Unloading Device for Low Back Pain) |
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Otoplasty |
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Palatal Implants for Obstructive Sleep Apnea |
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Pelvic Vein Embolization |
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Percutaneous Disc Decompression Procedures (Manual, Automated or Laser Discectomy; and Nucleoplasty®) |
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Percutaneous Neuromodulation Therapy (PNT) for the Treatment of Pain |
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Percutaneous Vertebroplasty and Kyphoplasty |
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Positron Emission Tomography (PET) Scan for Oncology, Neurology, and Cardiology Applications |
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Prolotherapy |
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Quantitative Sensory Tests |
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Radiofrequency Bladder Neck Suspension for Treatment of Stress Incontinence in Women (SURx®) |
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Radiofrequency Volumetric Tissue Reduction (RFVTR) for Breathing Disorders |
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Respiratory Syncytial Virus (RSV) Prophylaxis |
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Rituxamab (Rituxan®) |
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Sacral Nerve Stimulation |
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Salivary Estriol Test for Preterm Labor |
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Salivary Hormone Tests |
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Scanning Laser Technologies for Retina and Optic Nerve Imaging |
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Scar Revision |
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Sensory Integration Therapy |
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Serial Dilution Endpoint Titration for Diagnosis and Treatment of Airborne Allergy |
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Serological Testing for Diagnosis and Management of Inflammatory Bowel Disease (pANCA/ASCA) |
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Speech Therapy |
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Subdermal Contraceptive Implant (Implanon™) |
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Sublingual, Oral or Intranasal Allergenic Extracts for Allergy Diagnosis and/or Immunotherapy |
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Surgical and Minimally Invasive Treatments for Benign Prostatic Hypertrophy/Hyperplasia (BPH) |
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Surgical Interruption of Pelvic Nerve Pathways for Treatment of Pelvic Pain (e.g. Presacral Neurectomy and Uterosacral Nerve Ablation) |
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Telehealth Services |
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Therapeutic Apheresis (TA) - Plasmapheresis, Plasma Exchange |
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Thermography |
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Thoracic Electrical Bioimpedance (TEB) for Cardiac Output Measurement |
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Tidal Knee Lavage for Osteoarthritis |
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Topographic Genotyping (PathFinderTG®) for Diagnosis of Cancer |
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Transcatheter Closure of Septal Defect or Patent Ductus Arteriosus |
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Transcranial Magnetic Stimulation (TMS) Therapy |
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Transilluminated Powered Phlebectomy (TIPP) for Varicose Veins of the Legs |
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Transmyocardial Revascularization |
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Transobturator Tape (TOT) Sling Treatment for Female Stress Urinary Incontinence |
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Trastuzumab (Herceptin®) |
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Trigger Point Dry Needling |
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Upright Magnetic Resonance Imaging (MRI) (Standing/Seated/Weight Bearing/Vertical/Positional MRI) |
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Urethral Bulking Agents for Urinary Incontinence |
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Uvulopalatoplasty for Sleep Disorders (Including Radiofrequency Uvulopalatoplasty [UP2 or UPP] and Laser-Assisted Uvulopalatoplasty [LAUP]) |
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Vacuum-Assisted Closure for Wound Healing |
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Vagus Nerve Stimulation |
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VasClip® |
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Virtual Colonoscopy (Computed Tomographic Colonography or Magnetic Resonance Colonography) |
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Virtual Reality (VR) Therapy for Phobias |
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Vision Therapy |
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Wireless Capsule Endoscopy (CE) and Capsule Technology to Verify Patency Prior to Capsule Endoscopy |
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Wireless Esophageal pH Monitoring (Bravo™ System) |
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X Stop® Interspinous Process Decompression (IPD) System |
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