Medical Policies

You can learn about QualCare’s Medical Coverage Policies which describe our evaluation and coverage of medical procedures, devices and medications. Note that we rely on evidenced based medical research of peer-reviewed literature.


Acne Treatment (rvwd 2012)

Actigraphy (rvwd 2013)

Acupuncture (rvwd 2012)

Alefacept ("Amivive") Therapy for Psoriasis (rvsd 2013)

Allergen Injections in Physician’s Office (rvwd 2012)

Alopecia Areata (rvwd 2012)

Amniocentesis (rvwd 2012)

Anticoagulation Therapy-Preoperative (rvwd 2012)

Applied Behavioral Analysis (Lovaas) (rvwd 2011)

Auditory Brainstem Implants (rvwd 2012)

Benlysta (new 2013)

Bio-identical Compounded Hormone Replacement Therapy (rvwd 2013)

Biofeedback for Urinary Incontinence (rvwd 2012)

Bisphosphonates for Injection (rvsd 2013)

Blepharoplasty (rvwd 2012)

Bloodless Surgery (rvwd 2013)

Bone Density Studies (rvwd 2012)

Bone Growth Stimulator (rvsd 2011)

Bone-Anchored Hearing Aid (BAHA) (rvwd 2013)

Botulinum Toxin (rvsd 2012)

Brachytherapy for In-Stent Restenosis in Native Coronary Arteries (rvsd 2011)

BRCA Testing (rvsd 2012)

Breast Cancer Gene Expression Assays (rvsd 2013)

Breast Ductal Lavage and Fiberoptic Breast Ductoscopy (rvwd 2012)

Breast Imaging (rvsd 2012)

Bronchial Thermoplasty (new 2011)

Cardiac Rehabilitation (rvwd 2012)

Cervical Cancer (HPV) Vaccine (rvwd 2012)

Cervical Cancer Screening(rvwd 2012)

Cervical Spine Traction Devices for Home Use (new 2013)

Chelation Therapy (rvwd 2012)

Chest Computerized Tomographic (CT) Scan for Screening (rvwd 2011)

Chiropractic Care (rvwd 2013)

Clinical Trials (rvwd 2012)

Cochlear Implants (rvwd 2012)

Cognitive Rehabilitation Therapy (rvwd 2012)

Cold Laser Therapy (rvwd 2012)

Colorectal Cancer Screening (rvsd 2012)

Complication(s) Following Non-Covered Services (rvwd 2012)

Continuous Passive Motion Devices (rvsd 2012)

Corneal Topography (rvsd 2013)

Coronary Artery Calcium Scoring (new 2012)

Cryotherapy with Cold Compression Devices (rvwd 2011)

CT Angiography (rvsd 2012)

Drug Device or Biologic (Off-Label Use) (rvwd 2012)

Electrical Stimulation Therapy for Wounds (rvsd 2013)

Endoscopic Management of Gastroesophageal Reflux Disease (GERD) (rvwd 2013)

Enhanced External Counterpulsation (EECP) (rvwd 2012)

Enteral and Oral Feeding (rvwd 2012)

Epidural and Paravertebral Anesthesia for Pain Management (rvwd 2012)

Epidural Injections (rvsd 2009)

Evoked Potentials (EP) Studies- Intraoperative (rvwd 2012)

Extracorporeal Shock Wave Lithotripsy (ESWL) (rvwd 2012)

Extracorporeal Shock Wave Therapy (ESWT, Orthotripsy -podiatric-orthopedic applications) (rvwd 2013)

Facet Joint Injections and Facet Joint Denervation (rvsd 2012)

Fentanyl, Oral Transmucosal (Actiq®, Fentora®) (rvwd 2012)

Fetal Cord Blood (rvwd 2012)

First Trimester Screening: Genetic Abnormalities (rvsd 2012)

Foot Care (rvwd 2013)

Foot Orthotics and Diabetic Shoes (rvwd 2012)

Gastric Bypass and Other Bariatric Surgical Procedures (rvsd 2013)

Glucose Monitoring (Continuous, Interstitial Fluid) (rvwd 2013)

Growth Hormone (GH) Therapy (rvwd 2011)

Hepatic Fibrosis in Hepatitis C: Noninvasive Testing (rvsd 2012)

Hyaluronan Injections (Viscosupplementation) (rvwd 2011)

Hyperbaric Oxygen Therapy (rvwd 2012)

Hysteroscopic Sterilization Procedures (rvsd 2012)

Infertility- Diagnostic (rvwd 2011)

Infertility- Therapeutic (rvwd 2011)

Influenza Vaccination (rvsd 2013)

Injectable Infliximab (“Remicade”) (rvsd 2013)

Insulin Pump (rvwd 2013)

Intervertebral Disc Prostheses (rvwd 2012)

Intracoronary Brachytherapy for In-Stent Restenosis (rvwd 2013)

Intradiscal Electrothermal Therapy (IDET) (rvwd 2011)

Intraocular Lens (IOL) (rvwd 2013)

Intrastromal Corneal Ring Segments (new 2011)

Intravenous and Subcutaneous Immunoglobulin (rvsd 2012)

Intravenous Iron Therapy (rvsd 2011)

Keloid Treatment and Scar Revision (rvwd 2013)

Kyphoplasty and Vertebroplasty (rvsd 2011)

Laser Treatment of Plaque Psoriasis (new 2011)

Lupron (Leuprolide) and other GnRH Analogs (rvsd 2013)

Lyme Disease Intravenous Therapy (rvwd 2011)

Marijuana for Medical Use (rvwd 2012)

Mastectomy for Gynecomastia (rvwd 2013)

Medical Maggot Therapy (new 2011)

Medical Necessity Definition (rvsd 2011)

Meningococcal Vaccine (rvsd 2011)

Moderate Sedation (rvsd 2011)

Naltrexone extended-release injectable suspension (Vivitrol) (new 2011)

Never Events (rvsd 2013)

New Technology Assessment/New Policies (rvwd 2012)

Nutritional Counseling (rvsd 2012)

Obstetrical Ultrasound (rvwd 2013)

Obstructive Sleep Apnea (OSA): Surgical Management (rvsd 2012)

Omalizumab (Xolair®) (rvwd 2013)

Orthognathic Surgery (rvsd 2011)

Oxygen Therapy for Home Use (rvsd 2013)

PET (Positron Emission Tomography) Scan (rvwd 2012)

Platelet-Rich Plasma (rvwd 2012)

Progesterone To Prevent Pre-Term Delivery (rvwd 2013)

Prolotherapy (rvwd 2013)

Prostate Px, Post-OP Px (new 2011)

Prothrombin Time Home Monitoring (rvwd 2013)

Proton Beam Therapy (rvsd 2013)

Pulmonary Rehabilitation (rvwd 2011)

Pulsed Electrical Stimulation for Arthritis (BioniCare® System) (new 2012)

Reconstruction Post Breast Surgery (rvwd 2012)

Recurrent Pregnancy Loss (RPL) – Diagnostic (rvsd 2013)

Reduction Mammoplasty (rvwd 2012)

Refractive Eye Surgery (rvsd 2012)

Respiratory Syncytial Virus(RSV) Prophylaxis with Synagis

Eculizumab (Soliris) for PNH (rvwd 2011)

Sacral Nerve Stimulation for Urinary Voiding Dysfunction and/or Fecal Incontinence (rvwd 2011)

Selective Internal Radiation Therapy (SIRT) (rvsd 2011)

Shingles (Zoster) Vaccine (rvsd 2011)

Single Photon emission Computed Tomography (SPECT) (rvwd 2012)

Skeletal Manipulation Under Anesthesia (rvwd 2013)

Sleep Disorder Breathing Testing (rvwd 2011)

Speech Therapy (rvwd 2011)

State Mandated Early Intervention (EIS) (rvwd 2011)

Sterotactic Radiosurgery and Radiotherapy (new 2012)

Sural Nerve Graft with Radical Prostatectomy (rvsd 2011)

Thermal Annular and Intradiscal Procedures for Discogenic Back Pain(rvsd 2013)

Thyrogen® (rvwd 2012)

Topographic Genotyping (PathFinder TG) (new 2011)

Trancranial Magnetic Stimulation (new 2011)

Transmyocardial Laser Revascularization (TMLR) (rvsd 2011)

Transvaginal Ultrasonography (non-obstetrical) (rvwd 2012)

Trigger Point Injections (rvwd 2013)

Tumor Chemotherapy Sensitivity and Resistance Assays (rvwd 2012)

Vacuum-Assisted/Negative Pressure Wound Therapy (rvwd 2013)

Varicose Vein Interventions (Lower Extremities (rvsd 2013)

Ventricular Assist Devices (VAD) (rvsd 2008)

Vertebral Axial Decompression (VAX-D®, DRX9000®) (rvsd 2013)

Victoza (liraglutide [rDNA origin] injection) (new 2011)

Video and Ambulatory EEG Monitoring (rvwd 2013)

Vitamin B-12 Therapy (injectable) (rvwd 2011)

Weight Loss Treatment (non-Surgical) (rvsd 2013)

Wellness Benefits: Adult and Pediatric (rvsd 2011)

Whole Body Cutaneous Photography (WBCP) (rvwd 2013)

Wigs (rvwd 2011)

Wireless Capsule Endoscopy (rvwd 2012)

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