Policies and Guidelines > Coverage Policies
Coverage Policies
Coverage policies are developed to communicate Medica 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.
Both the coverage policy and utilization management policy sections should be checked to determine coverage for a particular service.
Important note: Before using these policies, read the Coverage Policies Usage Notice.
Medical Technology Assessment Submission
Use this form (PDF) to submit an inquiry regarding an existing Medica Coverage Policy or to submit information on a new technology. Please review this Provider & Vendor FAQ’s before submitting your inquiry.
Coverage Policies
- Access Techniques for Lumbar Interbody Fusion (PDF)
- Actigraphy (PDF)
- Allogeneic Pancreatic Islet Cell Transplantation (PDF)
- Amino Acid-Based Elemental Formula (PDF)
- Annulus Fibrosus Repair Devices (PDF)
- Autologous Blood-Derived Products (Platelet-Rich Plasma, Autologous Conditioned Serum, Autologous Whole Blood) – (PDF)
- Automated, Nerve Conduction Velocity (NCV) Testing (PDF)
- Biochemical Biomarker Panels for Assessing Hepatitis-Associated Liver Disease (PDF)
- Bioimpedance Spectroscopy (BIS) and Bioelectrical Impedance Analysis (BIA) (PDF)
- Birth Centers (Free-standing) – (PDF)
- Blood Coagulation Home Testing Devices (PDF)
- Bone Anchored Hearing Aid (BAHA) – (PDF)
- Breast Ductal Lavage (PDF)
- Breast Magnetic Resonance Imaging (MRI) – (PDF)
- Breast-Specific Gamma Imaging Scintimammography and Molecular Breast Imaging (PDF)
- Bronchial Thermoplasty (PDF)
- Cala Trio Therapy for Essential Tremor (PDF)
- Cardiac Event Monitors (PDF)
- Carotid Intima-Media Thickness Measurement (PDF)
- Cell Therapy Treatment of Cardiac Disease (PDF)
- Chemiluminescent Testing (ViziLite®) for Oral Cancer Screening (PDF)
- Chemoembolization for Hepatic Tumors (PDF)
- Chronic Rhinitis: Cryoablation, Radiofrequency Ablation and Laser Ablation, Office-Based (PDF)
- CLEAR Institute Scoliosis Treatment Protocols (PDF)
- Clinical Trial Participation (PDF)
- Cognitive Rehabilitation/Remediation (PDF)
- Collagen Cross Links Tests as Markers of Bone Turnover (PDF)
- Computerized Dynamic Posturography (PDF)
- Confocal Laser Endomicroscopy for Barrett's Esophagus (PDF)
- Continuous Glucose Monitoring (CGM) Systems (PDF)
- Corneal Cross-Linking (PDF)
- Coronary Artery Calcium Scoring (CACS) – (PDF)
- Coronary Computed Tomography Angiography (CCTA) for Coronary Artery Evaluation (PDF)
- Cranial Electrotherapy Stimulation (CES) – (PDF)
- Craniosacral Therapy (PDF)
- CT Colonography, MR Colonography, CT UGI Endoscopy (PDF)
- Cytotoxic Testing for Allergy Diagnosis (PDF)
- Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in Multiple Sclerosis (PDF)
- Drug Eluting Sinus Stents (PDF) (PDF)
- Durable Medical Equipment (DME) – (PDF)
- Elastography (PDF)
- Electric Cell Signaling (PDF)
- Electric Tumor Treatment Fields (PDF)
- Electrical or Electromagnetic Stimulation for Healing of Chronic Wounds (PDF)
- Electromagnetic Navigation Bronchoscopy (PDF)
- Endoscopic Balloon Sinuplasty (PDF)
- Endoscopic Procedures for Treatment of Gastroesophageal Reflux Disease (GERD) – (PDF)
- Endoscopic Radiofrequency Ablation for Barrett’s Esophagus (PDF)
- Enhanced External Counterpulsation (EECP) – (PDF)
- Epidural Lysis of Adhesions (PDF)
- Eustachian Tube Balloon Dilation (PDF)
- Exhaled Breath Tests for Asthma and Other Inflammatory Pulmonary Conditions: Exhaled Nitric Oxide Breath Test and Exhaled Breath condensate pH Measurement (PDF)
- Extracorporeal Magnetic Stimulation for the Treatment of Urinary Incontinence (PDF)
- Extracorporeal Photophoresis (Photochemotherapy) – (PDF)
- Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Indications and Soft Tissue Injuries (PDF)
- Fecal Calprotectin (PDF)
- Female External Urinary Catheters for Urinary Incontinence (e.g., PureWick, PrimaFit) (PDF)
- Foot Care (PDF)
- Food Allergy / Intolerance Testing (in vitro) – (PDF)
- Functional Magnetic Resonance Imaging (fMRI) – (PDF)
- Functional Electrical Stimulation (FES), Upper and Lower Limb – (PDF)
- Gastric Electrical Stimulation (PDF)
- Gastrointestinal Monitoring System (Smart Pill®) – (PDF)
- Genetic Testing: Aortopathies & Connective Tissue (PDF)
- Genetic Testing: Cardiac Disorders (PDF)
- Genetic Testing: Dermatologic Conditions (PDF)
- Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)
- Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)
- Genetic Testing: Eye Disorders (PDF)
- Genetic Testing: Gastroenterologic Disorders (Non-Cancerous) (PDF)
- Genetic Testing: General Approach to Genetic Testing (PDF)
- Genetic Testing: Hearing Loss (PDF)
- Genetic Testing: Hematologic Conditions (Non-Cancerous) (PDF)
- Genetic Testing: Hereditary Cancer Susceptibility (PDF)
- Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)
- Genetic Testing: Kidney Disorders (PDF)
- Genetic Testing: Lung Disorders (PDF)
- Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)
- Genetic Testing: Multisystem Inherited Disorders (PDF)
- Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)
- Genetic Testing: Oncology - Algorithmic Testing (PDF)
- Genetic Testing: Oncology - Cancer Screening (PDF)
- Genetic Testing: Oncology - Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF) (PDF)
- Genetic Testing: Oncology - Cytogenetic Testing (PDF)
- Genetic Testing: Oncology - Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)
- Genetic Testing Pharmacogenetics (PDF)
- Genetic Testing: Preimplantation Genetic Testing (PDF) (PDF)
- Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss(PDF) (PDF)
- Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)
- Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)
- Glaucoma Surgical Treatments: Microstent Implantation (PDF)
- Hair Analysis in the Clinical Setting (PDF)
- High Intensity Focused Ultrasound (HIFU) Ablation Therapy (PDF)
- Home Use of Bilevel Positive Airway Pressure (BiPAP) for Conditions Other Than Obstructive Sleep Apnea (OSA) (PDF)
- Home Use of Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) for Obstructive Sleep Apnea (OSA) – (PDF)
- Hyperbaric Oxygen Chamber Therapy (HBOT) – (PDF)
- Implantable Deep Brain Stimulation (PDF)
- Implanted Peripheral Nerve Stimulators for Treatment of Pain (PDF)
- In Vitro Chemosensitivity and Chemoresistance Assays (PDF)
- Inhaled Nitric Oxide (iNO) Therapy (PDF)
- Intense Pulsed Light (IPL) Treatment for Dry Eye Disease (PDF)
- Interferential Current Stimulation (PDF)
- Intradiscal Electrothermal Therapy (IDET) – (PDF)
- Intraoperative Neurophysiologic Monitoring (PDF)
- Intraosseous Ablation of Basivertebral Nerve for Treating LowBack Pain (e.g., Intracept®) (PDF)
- Intravascular Shockwave Lithotripsy for Treatment of Coronary Artery Disease (PDF)
- Iris Prosthesis (Artificial Iris Devices. E.g., CustomFlex™) - (PDF)
- Irreversible Electroporation (NanoKnife® System) (PDF)
- Laboratory Tests (PDF)
- Laser Spine Surgeries (PDF)
- Laser Therapy for Nicotine Dependence (PDF)
- Laser Therapy for Treatment of Pain (PDF)
- Left Atrial Appendage Closure Devices (PDF)
- Light Treatment and Laser Therapies for Benign Dermatologic Conditions (PDF)
- Lipoprotein Subclass Testing for Screening, Evaluation, and Monitoring of Cardiovascular Disease (PDF)
- Lipoprotein-associated Phospholipase A2 (Lp-PLA2) Immunoassay for Prediction of Risk for Coronary Heart Disease or Ischemic Stroke (PLAC® Test) – (PDF)
- Liposuction for Lymphedema Lipedema (PDF)
- Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening (PDF)
- Magnetic Resonance Spectroscopy (MRS) – (PDF)
- Mechanical Circulatory Support Device (PDF)
- Mechanical Stretching Devices for the Treatment of Joint Contractures of the Extremities (PDF)
- Mechanized Spinal Decompression Traction Tables for Low Back Pain (PDF)
- Meibomian Gland Evacuation Therapies (PDF)
- Mild® Procedure (mild® Device Kit) – (PDF)
- Minced Cartilage (Allograft) Repair for Articular Cartilage Defects (PDF)
- Motion Preserving Posterior Interspinous/Interlaminar Decompression/Stabilization Devices (PDF)
- Multichannel Intraluminal Esophageal Impedance with pH Monitoring (PDF)
- Myocardial Strain Imaging (PDF)
- Myoelectric Upper Limb Prosthetics and Orthotics (PDF)
- Nasal Expiratory Positive Airway Pressure (Provent®) for Obstructive Sleep Apena (PDF)
- Nasal Implant, Absorbable, for Treatment of Nasal Valve Collapse (PDF)
- Nebulized Intranasal Antibiotics/Antifungals for Sinusitus (PDF)
- Negative Pressure Wound Therapy with Instillation Systems (PDF)
- Noncontact Normothermic Wound Therapy (PDF)
- Noncontact Low-frequency Ultrasound Therapy for Healing of Chronic Wounds (PDF)
- Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (PDF)
- Non-Pneumatic Compression Systems or Garments (e.g., Dayspring) – (PDF)
- Non-Powered or Single Use Negative Pressure Wound Therapy Systems (PDF)
- Nutrition Counseling (PDF)
- OrthotracTM Pneumatic Vest (Spinal Unloading Device for the Treatment of Low Back Pain) – (PDF)
- Outdoor Behavioral Healthcare (PDF)
- Palatal Implants for Obstructive Sleep Apnea (PDF)
- Pelvic Vein Embolization (PDF)
- Percutaneous Disc Decompression Procedures (Percutaneous Discectomies, Nucleoplasty) – (PDF)
- Percutaneous Neuromodulation Therapy (PNT) for the Treatment of Pain (PDF)
- Percutaneous Tibial Nerve Stimulation (PDF)
- Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty (PDF)
- Percutaneous Ultrasonic Ablation of Soft Tissue (PDF)
- Photodynamic Therapy with Visudyne® (verteporfin) for Ocular (PDF)
- Phrenic Nerve Stimulation for Central Sleep Apnea (PDF)
- Powered Robotic Lower-Limb Exoskeleton Devices (PDF)
- Prolotherapy (PDF)
- Quantitative Electroencephalogram (qEEG) and Referenced Electroencephalogram (rEEG) – (PDF)
- Quantitative Sensory Tests (PDF)
- Radioembolization for Hepatic Tumors (PDF)
- Radiofrequency Ablation of Uterine Fibroids (PDF)
- Radiofrequency Volumetric Tissue Reduction (RFVTR) for Obstructive Sleep Apnea (PDF)
- Recombinant Human Bone Morphogenic Protein-2 (rhBMP-2)/InFUSE and Allogeneic Morphogenic Protein (OsteoAMP™) – (PDF)
- Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) – (PDF)
- Residential Facility and Outpatient Urine Drug Testing (UDT), Presumptive and Definitive (PDF)
- Sacral Nerve Stimulation (PDF)
- Salivary Estriol Test for Preterm Labor (PDF)
- Salivary Hormone Tests (PDF)
- Scanning Laser Technologies for Retina and Optic Nerve Imaging (PDF)
- Scar Revision (PDF)
- Scrambler Pain Therapy (PDF)
- Sensory and Auditory Integration Therapies (PDF)
- Serial Dilution Endpoint Titration for Diagnosis and Treatment of Airborne Allergy (PDF)
- Single Photon Emission Computed Tomography (SPECT) for Attention Deficit Hyperactivity Disorder (ADHD) – (PDF)
- Skin and Soft Tissue-Engineered Substitutes for Wound and Surgical Care (PDF)
- Sleep Studies for Initial Diagnosis of Obstructive Sleep Apnea (PDF)
- Sphenopalatine Ganglion Block for the Treatment of Headache (PDF)
- Stem Cell and Cellular Bone Matrix Products for Orthopedic Applications (PDF)
- Stem Cell Therapy for Peripheral Artery Disease (PDF)
- Subacromial Tissue Spacer for Rotator Cuff (PDF)
- Surgical and Minimally Invasive Treatments for Benign Prostatic Hypertrophy (BPH) – (PDF)
- Surgical Interruption of Pelvic Nerve Pathways for Treatment of Pelvic Pain (e.g., Presacral Neurectomy and Uterosacral Nerve) – (PDF)
- Synthetic Cartilage Implants for First Metatarsophalangeal Joint (PDF)
- Synthetic Ceramic-Based and Bioactive Glass Bone Substitutes/Fillers (PDF)
- Telehealth (PDF)
- Testing for Neutralizing Antibodies to Interferon Beta in the Management of Multiple Sclerosis (PDF)
- Therapeutic Apheresis (TA) - Plasmapheresis, Plasma Exchange (PDF)
- Thermography (PDF)
- Thoracic Electrical Bioimpedance (TEB) for Cardiac Output Measurement (PDF)
- Three Dimensional (3-D) Printed Anatomic Modeling for Surgical Planning (PDF)
- Tidal Knee Lavage for Osteoarthritis (PDF)
- Tongue Base Suspension Surgery for Obstructive Sleep Apnea (PDF)
- Total Ankle Replacement (PDF)
- Transcatheter Closure of Cardiac Defects (PDF)
- Transcatheter Heart Valve Replacement and Repair Procedures (PDF)
- Transcranial Magnetic Stimulation (PDF)
- Transcutaneous Electrical Joint Stimulation Devices (PDF)
- Transvaginal and Transurethral Radiofrequency (RF) Treatments of Stress Urinary Incontinence in Women (PDF)
- Trigger Point Dry Needling (PDF)
- Upright Magnetic Resonance Imaging (MRI) (Standing/Seated/Weight Bearing/Positional MRI) – (PDF)
- Urethral Bulking Agents for Urinary Incontinence (PDF)
- Uvulopalatoplasty (UP2, UPP) and Laser-Assisted Uvulopalatoplasty (LAUP) for Sleep-Related Breathing Disorders (PDF)
- Vaginal Tactile Imaging (PDF)
- Vestibular Evoked Myogenic Potentials (VEMP) – (PDF)
- Virtual Care (PDF)
- Vitamin D Testing for Screening (PDF)
- VivAer Airway Remodeling for Airway Obstruction (PDF)
- Volara Oscillation and Lung Expansion (PDF)
- Wireless Capsule Endoscopy and Capsule Technology to Verify Patency Prior to Capsule Endoscopy (PDF)
- Wireless Pulmonary Artery Pressure Monitoring Systems for Monitoring Heart Failure (CardioMEMS) – (PDF)