Coverage Policies

Medical Technology Assessment Submission

Use this form 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)
• Apolipoprotein E (APOE) Genetic Testing for Prediction and Management of Cardiovascular Disease (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 Liver Disease (PDF)
• Bioimpedance Spectroscopy (BIS) and Bioelectrical Impedance Analysis (BIA)
• Birth Centers (Free-standing) – (PDF)
• Bladder Cancer Screening, Diagnosis and Monitoring using Ancillary Urinary Tests (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)
• Cardiac Event Monitors (PDF)
• Carotid Intima-Media Thickness Measurement (PDF)
• Cell Therapy Treatment of Cardiac Disease (PDF)
• Cervicography (PDF)
• Chemiluminescent Testing (ViziLite^®) for Oral Cancer Screening (PDF)
• Chemoembolization for Hepatic Tumors (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 for Managing Diabetes (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)
• Cytochrome P450 (CYP450) Variant Genotyping (e.g., CYP2D6, CYP2C9, CYP2C19, CYP1A2, CYP3A4) – (PDF)
• Cytotoxic Testing for Allergy Diagnosis (PDF)
• Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in Multiple Sclerosis (PDF)
• Dietitian Services (PDF)
• Donor-Derived Cell-Free Testing to Detect Rejection in Kidney Transplantation (PDF)
• Drug Eluting Sinus Stents (PDF)
• Durable Medical Equipment (DME) – (PDF)
• Elastography
• 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)
• Expanded Carrier Testing for Genetic Disease (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)
• Eye Movement Desensitization and Reprocessing for Trauma (PDF)
• Fecal Calprotectin (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)
• Gene Expression Profiling Assays for Breast Cancer (PDF)
• Gene Expression Profiling for Assays Cancer of Unknown Origin (PDF)
• Gene Expression Profiling for Detection of Heart Transplantation Rejection (PDF)
• Gene Expression Profiling for Melanoma (PDF)
• Gene Expression Profiling Assay for Prediction of Coronary Artery Disease (PDF)
• Genetic and Pharmacogenetic Testing (PDF)
• Genetic Testing for Alzheimer Disease (PDF)
• Genetic Testing for Cardiomyopathies (PDF)
• Genetic Testing for Cardiac Channelopathies (PDF)
• Genetic Testing for Colorectal Cancer (PDF)
• Genetic Testing for Inherited Susceptibility to Melanoma (PDF)
• Genetic Testing for Prostate Cancer (PDF)
• Genetic Testing for Thyroid Cancer (PDF)
• Genetic Testing: ScoliScore^TM Adolescent Idiopathic Scoliosis (AIS) Prognostic Test (PDF)
• Genetic Testing: TP53 (p53) Testing for Li-Fraumeni Syndrome (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)
• Irreversible Electroporation (NanoKnife^® System)
• KRAS Mutation Analysis for Predicting Response to Drug Therapy (PDF)
• Laboratory Tests (PDF)
• Laser Spine Surgeries (PDF)
• Laser Therapy for Nicotine Dependence (PDF)
• Laser Therapy for Treatment of Pain (PDF)
• Laser Treatments for Neovascularization Associated with Macular Degeneration (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)
• Liquid Biopsy: Testing of Circulating Tumor Cells or Cell-Free Tumor DNA (PDF)
• Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening (PDF)
• Lower Limb Activity-Based Locomotor Exercise (ABLE) Training (PDF)
• Magnetic Resonance Spectroscopy (MRS) – (PDF)
• Magnetoencephalography and Magnetic Source Imaging (PDF)
• Maternal Plasma Testing for Detection of Cell-Free Fetal DNA for Analysis of Chromosomal Aneuploidies (PDF) 
• Measurement of Serum Drug and Antibody Levels to Infliximab, Adalimumab, Ustekinumab and Vedolizumab (PDF)
• Mechanical Circulatory Support Device (PDF)
• Mechanized Spinal Decompression Traction Tables for Low Back Pain (PDF)
• Meibomian Gland Evacuation Therapies (PDF)
• Meniett^TM Portable Pulse Generator for Treatment of Meniere's Disease (PDF)
• Methylenetetrahydrofolate Reductase (MTHFR) Gene Mutation Testing (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)
• Multivariate Biomarker Blood Testing for Predicting Malignancy in Women with Adnexal Mass (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)
• 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-Powered or Single Use Negative Pressure Wound Therapy Systems
• Orthotrac^TM Pneumatic Vest (Spinal Unloading Device for the Treatment of Low Back Pain) – (PDF)
• Outdoor Behavioral Healthcare (PDF)
• Palatal Implants for Obstructive Sleep Apnea (PDF)
• PancraGEN™ Genotyping for Risk Assessment of Pancreatic Cancer
• 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)
• Pharmacogenetic Testing of the VKORC1 Gene for Wararin Response (PDF)
• Pharmacogenetic Testing to Predict Toxicity to 5-Fluorouracil (5-FU)/Capecitabine-Based Chemotherapy (PDF)
• Photodynamic Therapy with Visudyne^® (verteporfin) for Ocular (PDF)
• Powered Robotic Lower-Limb Exoskeleton Devices (PDF)
• Prolotherapy (PDF)
• Prostate Health Index (PHI) – (PDF)
• Proton Beam Radiation Therapy (PDF)
• Quantitative Electroencephalogram (qEEG) and Referenced Electroencephalogram (rEEG) – (PDF)
• Quantitative Sensory Tests (PDF)
• Radioembolization for Hepatic Tumors (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)
• Sacral Nerve Stimulation (PDF)
• Sacroiliac Joint Fusion (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)
• Serological Markers for Diagnosis and Management of Inflammatory Bowel Disease (IBD) or Irritable Bowel Syndrome (PDF)
• Single Nucleotide Polymorphism (SNP) Genetic Testing for Assessment of Cancer Risk (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 Polysomnography and Home Sleep Studies (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)
• 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)
• Telemedicine (Emergency) – (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)
• 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)
• Urine Drug Testing (UDT) in the Outpatient Setting (PDF)
• Urine Drug Testing (UDT) for Residential Substance Abuse Treatment (PDF)
• Uvulopalatoplasty (UP2, UPP) and Laser-Assisted Uvulopalatoplasty (LAUP) for Sleep-Related Breathing Disorders (PDF)
• Vaginal Tactile Imaging (PDF)
• VeriStrat^® Proteomic Testing (PDF)
• Vestibular Evoked Myogenic Potentials (VEMP) – (PDF)
• Virtual Care (PDF)
• Vitamin D Testing for Screening (PDF)
• VivAer Airway Remodeling for Airway Obstruction (PDF)
• Whole Genome Sequencing (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)
• XEN^® Glaucoma Treatment System (PDF)