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Medical Policies

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Documents for Medical Policies

  • /app/files/public/4641/pdf-medicalpolicies-9202Abor.pdf Abortions (Surgical or Pharmacological) Show Details
    Description
    (MP9202) Prior authorization through the Medical Affairs Division is required to determine whether an abortion will be covered on the grounds of medical necessity.
    Last Updated
    2/13/2014
  • /app/files/public/4593/pdf-medicalpolicies-9023Acne.pdf Acne Show Details
    Description
    (MP9023) Dean Health Plan's Medical Policy on the treatment of Acne. (Related: dermabrasion, collagen, hyperbaric, photodynamic therapy, acne vulgaris, cystic acne, Dermatology)
    Last Updated
    2/13/2014
  • /app/files/public/4726/pdf-medicalpolicies-9355AminoAcidBasedFormulas.pdf Amino Acid-Based Formulas (Neocate, Elecare, Nutramigen AA) Show Details
    Description
    (MP9355) Amino acid based formulas require prior authorization through the Medical Affairs Division. (Related: Eosinophilic esophagitis, atopy or eczema, food allergy, formula protein intolerance, cystic fibrosis, fatty acid, metabolic or malabsorption disorders)
    Last Updated
    2/13/2014
  • /app/files/public/4749/pdf-medicalpolicies-9382AngioplastyofCarotid-and-Vertebral-arteries.pdf Angioplasty and Stenting of Extra-Cranial and Intra-Cranial Arteries Show Details
    Description
    (MP9382) Percutaneous transluminal angioplasty of the extra-cranial carotid arteries and vertebral arteries, with or without stent implantation and embolic protection, requires prior authorization through the Medical Affairs Division. (Related: stenosis, intracranial.)
    Last Updated
    2/13/2014
  • /app/files/public/4735/pdf-medicalpolicies-9364Dynesys.pdf Artificial Intervertebral Discs Show Details
    Description
    (MP9364) Artificial cervical disc systems require prior authorization through the Medical Affairs Division and are considered medically appropriate when all of the criteria in the medical policy are met. (related: cervical surgery, intractable radiculopathy, myelopathy, facet disease, sagittal balance)
    Last Updated
    2/13/2014
  • /app/files/public/4589/pdf-medicalpolicies-9016Coch.pdf Auditory Brain Stem and Cochlear Implants Show Details
    Description
    (MP9016) Cochlear implant requests for members with bilateral sensorineural hearing impairment must meet criteria described in policy. (Related: Ossification, Auditory brain stem implant, bilateral resection of neurofibromas.)
    Last Updated
    2/13/2014
  • /app/files/public/4662/pdf-medicalpolicies-9261Back-LSO.pdf Back or Spinal Orthosis: Lumbosacral (LSO) or Thoracolumbosacral (TLSO) Show Details
    Description
    MP9261 Back or Spinal Orthosis: Lumbosacral (LSO) or Thoracolumbosacral (TLSO) (Related: LSO, TLSO, orthotics, DME, Neurology, Nuerosurgery, Orthopedics, Sports Medicine, Occupational Medicine, Rheumatology)
    Last Updated
    2/13/2014
  • /app/files/public/5665/pdf-medicalpolicies-DHP9434BariatricOutpatient.pdf Bariatric Outpatient Services Show Details
    Description
    (MP9434) Bariatric services are a covered benefit only for those plans whose certificates include a comprehensive weight management program benefit rider. Authorization may only be granted after a consultation with a Dean Comprehensive Weight Management Program provider. Only certain Dean providers qualify as Program providers.
    Last Updated
    6/25/2013
  • /app/files/public/4706/pdf-medicalpolicies-9319Bariatric-Surgery.pdf Bariatric Surgery Show Details
    Description
    (MP9319) All bariatric surgeries and any follow-up surgeries require prior authorization through the Medical Affairs Department. (Related: Obstructive sleep apnea, Laparoscopic gastric banding, bypass.)
    Last Updated
    2/13/2014
  • /app/files/public/4636/pdf-medicalpolicies-9163-Biofeedback.pdf Biofeedback Show Details
    Description
    (MP9163) Biofeedback therapy is the process of furnishing an individual information, usually in an auditory or visual mode, on the state of one or more physiological variables such as heart rate, blood pressure, or skin temperature; such a procedure often enables the individual to gain some voluntary control over the physiologic variable being sampled. (RElated: muscle function, migraine headaches, LBP, TMD.)
    Last Updated
    2/13/2014