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Preferred Care Medical Policies

• This Web page displays links to all current Preferred Care medical policies

• Policies in the integrated MVP/Preferred Care format are indicated in green.

• Updated policies include an "update effective" date in orange next to the Web link.

• Next to updated policies is a link to "see policy w/ updates indicated," in which changes from the previous version are shown.

• Policies that have recently been updated include a "see last update(s)" link next to the current policy

Click on a letter of the alphabet to "jump" to that section:

Also See:

Archive Clinical Guidelines Forms Pharmaceutical Policies

A
Acute Inpatient Rehabilitation (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Age-Related Macular Degeneration (AMD) Treatments(Update effective 12/01/07)	see policy w/update(s) indicated	see previous update(s)
Air Medical Transport (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Allergy Testing & Allergen Immunotherapy (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Alopecia / Wigs / Scalp Prosthesis (Annual review 08/01/08)		see previous update(s)
Ambulatory Holter Monitors and 30-day Cardiac Event Recorders/Monitors (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
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B
Benign Skin Lesions (Annual review 08/01/08)		see previous update(s)
Biofeedback Therapy (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Blepharoplasty/Browlift/Ptosis Repair (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Bone Density Study for Osteoporosis (Dexa Scan)(Update effective 02/01/08)	see policy w/update(s) indicated	see previous update(s)
Bone Growth Stimulator (Update effective 12/01/07)	see policy w/update(s) indicated	see previous update(s)
Botulinum Toxin Treatment (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Brachytherapy for Breast Cancer (NEW effective 02/01/08)
Breast Implantation (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Breast Reconstruction Surgery
Breast Reduction Surgery (Reduction Mammoplasty) (Update effective 6/01/08)	see policy w/update(s) indicated	see previous update(s)
Breast Surgery in Males for Gynecomastia (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Buprenorphine Maintenance/Opioid Substitution Therapy (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
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C
Capsule Endoscopy (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Cardiac Rehabilitation Phase II (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Cardiac Revascularization (Coronary Artery Bypass Surgery, External Enhanced Couterpulsation, Intravascular Brachytherapy, Transmyocardial Laser Revascularization, Drug Eluting Stents) (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Chemical Dependency (Annual review 08/01/08)		see previous update(s)
Chiropractic Care
Cochlear Implants & Osseointegrated Devices (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Continuous Passive Motion Device (NEW effective 07/01/07)
Computed Tomography Abdomen
Computed Tomography Abdomen and Pelvis
Computed Tomography Brain
Computed Tomography Cervical, Thoracic, Lumbar Spine
Computed Tomography Chest
Computed Tomography for Coronary Arterial Disease(Update effective 01/01/08)	see policy w/update(s) indicated	see previous update(s)
Computed Tomography for Extremity
Computed Tomography Neck
Computed Tomography Orbit
Computed Tomography Pelvis
Computed Tomography of the Sinuses
Continuous Glucose Monitor System (Update effective 01/01/08)	see policy w/update(s) indicated	see previous update(s)
Cosmetic and Reconstructive Services and Surgery
Cryocuff Compression Dressing (DME)
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D
Dental Care Services
Dermabrasion
Diabetic Therapeutic Shoes
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E
Eating Disorders(Update effective 12/01/07)	see policy w/update(s) indicated	see previous update(s)
Electrical Stimulation for the Treatment of Chronic Wounds
Electric Wheelchairs and Power Scooters
Electromyography (EMG) and Nerve Conduction Studies (NEW effective 01/01/08)
Endovascular Procedures(Update effective 12/01/07)	see policy w/update(s) indicated	see previous update(s)
Enteral Formulas and Oral Nutritional Therapy for Vermont and New Hampshire
Erectile Dysfunction (Update effective 01/01/08)	see policy w/update(s) indicated	see previous update(s)
Evaluation of New Technology, Procedures, Behavioral Health Services and Programs (NEW effective 01/01/08)
Experimental or Investigational Procedures(NEW effective 08/01/08)
External Breast Prosthesis
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Indications(Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
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F
FluMist (Update effective 06/01/08)	see policy w/update(s) indicated
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G
Genetic Counseling
Genetic Testing
Genetic Testing for Susceptibility to Breast and Ovarian Cancer (BRCA1 and BRCA2) (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Ground Ambulance Services/Ambulette Services
Growth Hormone Therapy (refer to Growth Hormone Therapy in Pharmacy Policies)
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H
High Frequency Chest Wall Oscillation Devices(ThAIRpy Vests) (Update effective 02/01/08)	see policy w/update(s) indicated	see previous update(s)
Home Care Services		see previous update(s)
Home Uterine Activity Monitoring (Ambulatory Uterine Monitoring) (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Home Prothrombin Time Monitoring (INR Monitoring Device) (NEW effective 12/01/07)
Hospice Care		see previous update (s)
Hyaluronic Acid Derivatives (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Hyperbaric Oxygen Therapy (HBO) (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Hyperhidrosis Treatments (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
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I
Immunizations – Childhood, Adolescent and Adult
Implantable Cardioverter Defibrillators, Implantable Dual Chamber Automatic Defibrillators, Cardiac Resynchronization Devices (Update effective 02/01/08)	see policy w/update(s) indicated	see previous update(s)
Infertility - Involuntary (Update effective 04/01/08)	see policy w/update(s) indicated	see previous update(s)
Infertility A Policy Vermont (except FEHB HMO members) New Hampshire and ASO groups (Update effective 06/01/07)	see policy w/update(s) indicated
Injection Procedures for the Management of Chronic Spinal Pain/Chronic Pain (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Insulin Infusion Pump (External Continuous Subcutaneous) (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Intensity Modulated Radiation Therapy (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Intrafallopian Tube Birth Control Device
Investigational & Adjunctive Technologies
Immunoglobulin Therapy (Update effective 12/01/07)	see policy w/update(s) indicated	see previous update(s)
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J
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K
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L
Laser Treatment for Port Wine Stains, Hemangiomas, Warts and Rosacea (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Left Ventricular Assist Device
Lenses for Medical Conditions of the Eye (NEW effective 04/01/08)
Light Therapy for Seasonal Affective Disorder (SAD)
Low Vision Aids (NEW effective 07/01/07)
Lyme Disease / IV Antibiotic Treatment / Home Care
Lymphedema Pumps and Compression Garments/Appliances (Update effective 09/01/07)	see policy w/update(s) indicated	see previous update(s)
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M
Magnetic Resonance Angiogram (MRA) - Brain
Magnetic Resonance Angiogram (MRA) - Carotid
Magnetic Resonance Angiogram (MRA) - Kidney
Magnetic Resonance Angiogram (MRA) - Lower Extremity
Magnetic Resonance Imaging (MRI) - Abdomen, Pelvis
Magnetic Resonance Imaging (MRI) - Brain
Magnetic Resonance Imaging (MRI) - Breast
Magnetic Resonance Imaging (MRI) - Cervical Spine, Thoracic Spine
Magnetic Resonance Imaging (MRI) - Chest
Magnetic Resonance Imaging (MRI) - Extremity
Magnetic Resonance Imaging (MRI) - Hip/Knee
Magnetic Resonance Imaging (MRI) - Lumbar Spine
Magnetic Resonance Imaging (MRI) - Neck
Magnetic Resonance Imaging (MRI) - Pituitary
Magnetic Resonance Imaging (MRI) - Shoulder/Wrist
Magnetic Resonance Imaging (MRI) - Temporomandibular Joint (TMJ)
Magnetic Resonance Spectroscopy (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Medical Policy Development, Implementation and Review Process (Update effective 09/01/07)	see policy w/update(s) indicated	see previous update(s)
Mental Health Services (Annual review 08/01/08)		see previous update(s)
Metal-on-Metal Total Hip Resurfacing (NEW effective 02/01/08)
Methadone Maintenance/Opioid Substitution Therapy (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Mifepristone (RU 486) (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
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N
Needle-free Insulin Injectors(Vitajet Injector) (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Nesiritide Infusion (Outpatient) for Heart Failure
Neuropsychological Testing (Annual review 08/01/08)		see previous update(s)
Nuclear Stress Test -Thallium /Technetium /Sestamib /Technetium /Tetrofosmin (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Nutritional Counseling
Nutritional Therapy (Supplemental & Sole Source) (New York)
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O
Obstructive Sleep Apnea and Other Conditions: Non-surgical Treatments (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Obstructive Sleep Apnea: Surgical Treatment (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Omalizumab (Xolair)(refer to Omalizumab (Xolair) in Pharmacy Policies)
Oncotype DX Test/Breast Cancer Prognosis (Update effective 02/01/08)	see policy w/update(s) indicated	see previous update(s)
Optic Nerve and Retinal Imaging (Update effective 02/01/08)	see policy w/update(s) indicated	see previous update(s)
Organ Transplant
Orthognathic Surgery (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Orthotic Devices
Oxygen Therapy for the Treatment of Cluster Headaches (NEW effective 07/01/07)
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P
Panniculectomy and Abdominoplasty (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Pectus Excavatum
Percutaneous Vertebroplasty and Kyphoplasty
Phototherapeutic Keratectomy / Refractive Surgery (Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Podiatry
Positron Emission Tomography (PET) Scan / Brain
Positron Emission Tomography (PET) Scan Chest/Cardiac
Positron Emission Tomography (PET) Scan / Whole Body
Pressure Garments (NEW effective 08/01/07)
Private Duty Nursing Services (Update effective 06/01/07)	see policy w/update(s) indicated
Prolotherapy (Update effective 06/01/08)		see previous update(s)
Prophylactic Mastectomy/Prophylactic Oophorectomy
Prostatic Brachytherapy and Cryosurgery(Update effective 06/01/08)	see policy w/update(s) indicated	see previous update(s)
Prosthetic Devices (External) (NEW effective 08/01/07)
Psoriasis Treatment (Non-drug Therapy)(Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Pulmonary Rehabilitation (Respiratory Physical Therapy - Ambulatory) (Annual review 08/01/08)		see previous update(s)
Punctal Implants for Dry Eye Syndrome
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Q
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R
Radiofrequency Ablation for Spinal Pain Cervical/Lumbar)/Rhizotomy (Update effective 02/01/08)	see policy w/update(s) indicated	see previous update(s)
Respiratory Syncytial Virus / Snyagis® (palivizumb) (see Respiratory Syncytial Virus/Synagis® (palivizumab) in Pharmacy Policies)
Respiratory Therapy / Equipment
Rhinoplasty (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
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S
Sacral Nerve Stimulation with Implantable Neuroprosthesis (InterStim) for the Management of Urinary Incontinence and Urinary Retention (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Sclerotherapy for Varicose Veins of the Lower Extremities
Skin Endpoint Titration (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Sleep Studies for the Diagnosis of Obstructive Sleep Apnea
Speech Generating Devices (Update effective 06/01/08)		see previous update(s)
Speech Therapy (ST)
Spinal Cord Stimulator (SCS) for Intractable Pain (Update effective 08/01/08)	see policy w/update(s) indicated	see previous update(s)
Stereotactic Radiosurgery
Surgical Management of Morbid Obesity (Update effective 04/01/08)	see policy w/update(s) indicated	see previous update(s)
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T
Temporomandibular Joint Dysfunction (TMJ)
Temporomandibular Disorders (TMD) for Vermont members only (Update effective 06/01/07)
Treatment of Benign Prostatic Hypertrophy