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 (rvsd2015)

Actigraphy (rvwd 2013)

Acupuncture (DR) 2014

Acute Inpatient Treatment for Eating Disorders (new2015)

Acute Inpatient Treatment for Substance Use Disorders (new2015)

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

Allergen Injections in Physician's Office (rvwd 2014)

Alopecia Areata

Alternating Electric Field Therapy (new2015)

Amniocentesis (rvwd 2014)

Anticoagulation Therapy Preoperative (rvwd 2014)

Applied Behavioral Analysis (Lovaas) (rvwd 2015)

Auditory Brainstem Implants (rvwd 2014)

Benlysta (rvsd2015)

Bio-identical Compounded Hormone Replacement Therapy (rvwd 2013)

Biofeedback Urinary Incontinence (rvsd2014)

Bisphosphonates for Injection (rvsd 2013)

Blepharoplasty (rvwd 2012)

Bloodless Surgery (rvwd 2013)

Bone Density Measure (rvwd 2014)

Bone Growth Stimulator (rvsd2015)

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

Botulinum toxin (rvwd 2014)

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

BRCA Testing 2015 (rvsd 2015)

Breast Cancer Gene Expression (rvsd 2014)

Breast Ductal Lavage and Fiberoptic Breast Duct (rvsd 2014)

Breast Imaging (rvsd 2014)

Bronchial Thermoplasty (rvsd 2014)

Cardiac Rehabilitation

Cardiac Rehabilitation (rvwd 2012)

Cervical Cancer (HPV) Vaccine (rvwd 2014)

Cervical Cancer Screening(rvwd 2012)

Cervical Spine Traction Devices for Home Use (rvsd2015)

Chelation Therapy (rvsd2015)

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

Chiropractic Care (rvwd2015)

Clean Claim Definition

Clinical Trials (rvsd 2014)

Cochlear Implants (rvwd 2014)

Cognitive Rehabilitation Therapy (rvwd 2014)

Cold Laser Therapy (rvsd 2014)

Colorectal Cancer Screening (rvsd2015)

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

Continuous Passive Motion Devices (rvwd 2014)

Corneal Topography (rvsd 2013)

Coronary Artery Calcium Scoring (rvwd2015)

Cryotherapy with Cold Compression Devices (rvwd 2011)

CT Angiography (rvsd2015)

Drug and Alcohol Detoxification (new2015)

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

Eculizumab (Soliris) for PNH (rvwd 2011)

Electrical Stimulation Therapy for Wounds (rvsd 2013)


Enhanced External Counterpulsation (rvwd 2014)

Enteral and Oral Feeding (rvsd 2014)

Epidural Anesthesia (rvwd 2014)

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(rvsd2015)

Fentanyl (rvsd 2014)

Fetal Cord Blood (rvwd 2012)

First Trimester Screening Genetic Abnormalities (rvsd2015)

Foot Care (rvwd 2013)

Foot Orthotics and Diabetic Shoes (rvwd 2014)

Gastric Bypass and Other Bariatric Surgical Procedures (rvsd 2013)

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

Growth Hormone (GH) Therapy (rvwd 2013)

Hepatic Fibrosis in Hepatitis C: Noninvasive Testing (rvsd 2014)

Hepatic Fibrosis in Hepatitis C: Noninvasive Testing (rvsd 2014)

Hyaluronan Injections (Viscosupplementation) (rvwd 2013)

Hyperbaric Oxygen Therapy (rvsd2015)

Hysteroscopic Sterilization Procedures (rvwd 2014)

Infertility - Diagnostic (rvsd2015)

InfertilityTherapeutic (rvsd2015)

Influenza Vaccination (rvsd 2013)

Injectable Infliximab (“Remicade”) (rvsd 2013)

Insulin Pump (rvwd 2013)

Intensive Outpatient Treatment Substance Use Disorders (new2015)

Intervertebral Disc Prostheses (rvwd 2014)

Intracoronary Brachytherapy for In-Stent Restenosis (rvwd 2013)

Intradiscal Electrothermal Therapy (IDET) (rvwd 2011)

Intraocular Lens (IOL) (rvwd 2013)

Intraoperative Neurophysiology Monitoring (rvsd 2014)

Intrastromal Corneal Ring Segments (new 2011)

Intravenous and Subcutaneous Immunoglobulin (rvsd 2014)

Intravenous Iron Therapy (rvsd 2011)

IOPEatingDisorders (new2015)

IV Iron

Keloid Treatment and Scar Revision (rvwd 2013)

Kyphoplasty and Vertebroplasty (rvsd 2011)

Laser Treatment of Plaque Psoriasis (new 2011)

Lung Cancer Screen

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

Lyme Disease Intravenous Therapy (rvwd 2013)

Marijuana for Medical Use (rvwd 2012)

Mastectomy for Gynecomastia (rvwd 2013)

Medical Maggot Therapy (new 2011)

Medical Marijuana

Medical Necessity Definition (rvsd 2011)

Meningococcal Vaccine (rvsd 2013)

Moderate Sedation (rvsd 2011)

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

Never Events (rvsd 2013)

New Technology Assessment (rvsd2015)

Nutritional Counseling (rvsd 2014)

Obstetrical Ultrasound (rvwd 2013)

Obstructive Sleep Apnea Diagnostic Testing In Adults (rvsd 2014)

Obstructive Sleep Apnea Treatment (rvsd 2014)

Off Label Use (rvwd 2014)

Omalizumab (Xolair®) (rvwd 2013)

Orthognathic Surgery (rvsd2015)

Oxygen Therapy for Home Use (rvsd 2013)

Partial Hospitalization Substance Use Disorders (new2015)

Percutaneous Left Atrial Occlusion (new2015)

PET (Positron Emission Tomography) Scan (rvsd2015)

PET (Positron Emission Tomography) Scan (rvwd 2012)

PHP Eating Disorder (new2015)

Platelet Rich Plasma (rvwd 2014)

Pre-implantation Genetic Diagnosis (new2015)

Preconception genetic carrier

Preventative and Wellness Practice Guidelines

Progesterone To Prevent Pre-Term Delivery (rvwd 2013)

Prolotherapy (rvwd 2014)

Prostate Px, Post-OP Px (new 2011)

Prothrombin Time Home Monitoring (rvwd 2013)

Proton Beam Therapy (rvsd 2013)

Pulmonary Rehabilitation (rvwd 2014)

Pulsed Electrical Stimulation for Arthritis (BioniCare® System) (rvwd 2014)

Reconstruction Post Breast Surgery (rvwd 2014)

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

Reduction Mammoplasty (rvsd 2014)

Refractive Eye Surgery (rvsd 2014)

Residential Substance Use Disorders Treatment (new2015)

Respiratory Syncytical Virus (RSV) Prophylaxis with Synagis (rvwd 2014)

Sacral Nerve Stimulation for Urinary Voiding Dysfunction and-or Fecal Incontinence (rvwd 2013)

Selective Internal Radiation Therapy (rvsd2015)

Shingles (Zoster) Vaccine (rvsd 2011)

Single Photon Emission Computed Tomography (SPECT) (rvsd2015)

Skeletal Manipulation Under Anesthesia (rvwd 2013)

Sleep Disorder Breathing Testing (rvwd 2011)

Speech Therapy (rvwd 2011)

State Mandated Early Intervention (EIS) (rvwd 2014)

Stereotactic Radiosurgery and Radiotherapy (rvsd2015)

Sterotactic Radiosurgery and Radiotherapy (new 2012)

Sural Nerve Graft with Radical Prostatectomy (rvsd 2011)

Testosterone Replacement (new2015)

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

Thyrogen® (rvwd 2012)

Topographic Genotyping (PathFinder TG) (rvwd 2014)

Trancranial Magnetic Stimulation (new 2011)

Transmyocardial Laser Revascularization (TMLR) (rvsd 2011)

Transvaginal Ultrasonography (rvwd 2014)

Trigger Point Injections (rvwd 2013)

Tumor Chemotherapy Sensitivity and Resistance Assays (rvwd 2012)

Umbilical Cord Blood (rvsd 2014)

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 2014)

Whole Body Cutaneous Photography (WBCP) (rvwd 2013)

Wigs (rvwd 2011)

Wireless Capsule Endoscopy (rvsd 2014)

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