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- Interventional Procedures (rvsd2015)

Actigraphy (rvsd 2016)

Acupuncture (DR) 2014

Acute Inpatient Treatment for Eating Disorders (new2015)

Acute Inpatient Treatment for Substance Use Disorders (new2015)

Alternating Electric Field Therapy (new2015)

Amniocentesis (rvsd 2014)

Anti-Tumor Necrosis Factor therapy( TNF)(new 2016)

Anticoagulation Therapy-Preoperative (rvwd 2014)

Applied Behavioral Analysis(rvsd2015)

Auditory Brainstem Implant (rvsd 2014)

Benlysta (rvsd2015)

Biofeedback Urinary Incontinence (rvsd2014)

Bioidentical Compounded Hormone Replacement Therapy(rvsd 2015)

Bisphosphonates for Injection

Blepharoplasty (rvsd 2015)

Bloodless Surgery (rvwd 2016)

Bone Growth Stimulator (rvsd2015)

Bone-Anchored Hearing Aid (BAHA) (rvsd 2016)

Botulinum toxin (rvwd2014)

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

BRCA Testing 2015 (rvsd 2015)

Breast Cancer Gene Expression Assays (rvsd 2016)

Breast Ductal Lavage and Fiberoptic Breast Ductoscopy (rvsd 2014)

Breast Imaging (rvsd 2014)

Bronchial Thermoplasty (rvwd 2016)

Cardiac Rehabilitation (rvwd 2012)

Cardiac Rehabilitation (rvwd 2016)

Cervical Cancer (HPV) Vaccine (rvsd 2015)

Cervical Spine Traction Devices for Home Use (rvsd2015)

Chelation Therapy (rvsd2015)

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

Chiropractic Care (rvwd2015)

Clean Claim Definition

Clinical Trials (rvwd 2016)

Cochlear Implants (rvwd 2014)

Cognitive Rehabilitation Therapy (rvsd2014)

Cold Laser Therapy (rvsd 2014)

Colorectal Cancer Screening (rvwd 2016)

Continuous Passive Motion Devices (rvwd 2014)

Corneal Topography (rvsd 2016)

Coronary Artery Calcium Scoring (rvwd2015)

Cryotherapy with Cold Compression Devices (rvsd 2015)

CT Angiography (rvsd2015)

Drug and Alcohol Detoxification (new2015)

Drug, Device or Biologic (Off-Label Use) (rvwd 2016)

Eculizumab (Soliris) for PNH (rvwd 2011)

Electrical Stimulation Therapy for Wounds (rvsd 2016)


Enhanced External Counterpulsation (EECP) (rvwd 2014)

Enteral and Oral Feeding (rvsd 2014)

Epidural Injection (rvwd 2016)

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

Extracorporeal Shock Wave Therapy (ESWT, Orthotripsy [podiatricorthopedic applications]) (rvwd 2016)

Facet Joint Injections and Facet Joint Denervation(rvsd2015)

Fentanyl (rvsd 2014)

Fetal Cord Blood (rvwd 2012)

Fetanyl - Transmucosal Immediate Release (Actiqr, Fentorar, Abstralr, Onsolisr, SubsysT, Lazandar ) (rvsd 2014)

First Trimester Screening Genetic Abnormalities (rvsd2015)

Foot Orthotics and Diabetic Shoes (rvwd 2016)

Footcare (rvsd 2016)

Gastric bypass (rvsd 2016)

Gender Reassignment Surgery

Genetic testing (new 2013)

GeneticTesting Colon Rectal Ca (rvsd 2016)

GeneticTesting Colon Rectal Ca (rvsd 2016)

Glucose Monitoring Continuous (rvsd2016)

Gonadotropin-releasing hormone agonists and antagonists

Growth Hormone therapy(rvsd 2016)

Hepatic Fibrosis in Hepatitis C Noninvasive Testing (rvwd 2014)

Hepatic Fibrosis in Hepatitis C Noninvasive Testing (rvwd 2014)

Histrelin acetate subcutaneous implant

Hyaluronan Injections (Viscosupplementation (rvsd 2016)

Hyperbaric Oxygen Therapy (rvsd2015)

Hysteroscopic Sterilization Procedures (rvwd 2014)

Implantable Testosterone Replacement Therapy for Adult Male Hypogonadism (Testopel) (new2015)

Implantable Testosterone Replacement Therapy for Adult Male Hypogonadism (Testopel) (new2015)

Infertility - Diagnostic (rvsd2015)

InfertilityTherapeutic (rvsd2015)

Influenza Vaccination (rvsd 2016)

Injectable Infliximab ("Remicade") (rvsd 2013)

Insulin Pump (rvsd2016)

Intensive Outpatient Treatment for Eating Disorders (new2015)

Intensive Outpatient Treatment Substance Use Disorders (new2015)

Intervertebral Disc Prostheses (rvwd 2016)

Intracoronary Brachytherapy for In-Stent Restenosis (rvsd 2016)

Intradiscal Electrothermal Therapy IDET (rvwd 2011)

Intraocular lens (rvsd 2016)

Intraoperative Neurophysiology Monitoring IONM (rvwd 2016)

Intrastromal Corneal Ring Segments (new 2011)

Intravenous and Subcutaneous Immunoglobulin (rvwd 2016)

Intravenous Iron Therapy (rvwd 2016)

IOPEatingDisorders (new2015)

IV Iron (rvsd 2014)

Keloid Treatment and Scar-revision (rvsd 2016)

Kyphoplasty and Vertebroplasty (rvsd 2015)

Laser Treatment of Plaque Psoriasis (new 2011)

Lung cancer screen (rvsd 2016)

Lupron (leuprolide) and other injectable or GnRH Analogs (rvsd 2016)

Lyme disease (rvwd 2016)

Marijuana for Medical Use

Mastectomy for Gynecomastia (rvsd 2016)

Medical Marijuana

Medical Necessity Definition (rvwd 2016)

Meningococcal Vaccine (rvsd 2013)

Naltrexone Injection (rvsd 2016)

New Technology Assessment New Policies (rvsd2015)

Nutritional Counseling (rvwd 2016)

Obstetrical ultrasound (rvwd 2016)

Obstructive Sleep Apnea (OSA) Surgical Management (rvsd 2014)

Obstructive Sleep Apnea Diagnostic Testing In Adults (new 2014)

Off Label Use (rvwd 2014)

Omalizumab (Xolairr) (rvsd 2016)

Orthognathic Surgery (rvsd2015)

Oxygen Therapy for Home Use (rvsd 2015)

Partial Hospitalization for Eating Disorders (new2015)

Partial Hospitalization for Eating Disorders (new2015)

Partial Hospitalization Substance Use Disorders (new2015)

Percutaneous Left Atrial Appendage Closure Procedures (new2015)

Percutaneous Left Atrial Occlusion (new2015)

PET (Positron Emission Tomography) Scan (rvsd2015)

PHP Eating Disorder (new2015)

Platelet-Rich Plasma (rvwd 2014)

Pre-implantation Genetic Diagnosis (new2015)

Preconception Genetic Carrier Screening

Preventative and Wellness Practice Guidelines

Progesterone to Prevent PTD (rvsd 2016)

Prolotherapy (rvwd 2016)

Prothrombin Time Home Monitoring (rvsd 2016)

Proton Beam Therapy (rvsd 2013)

Pulmonary Rehabilitation (rvwd 2014)

Pulsed Electrical Stimulation for Arthritis (BioniCarer System) (rvwd 2014)

Reconstruction Post Breast Surgery (rvwd 2014)

Recurrent pregnancy loss (rvsd 2016)

Reduction Mammoplasty (rvwd 2016)

Refractive Eye Surgery (rvsd 2016)

Residential Substance Use Disorders Treatment (new2015)

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

Sacral Nerve Stimulation for Urinary voiding (rvsd 2016)

Selective Internal Radiation Therapy (rvsd2015)

Shingles (Zoster) Vaccine (rvwd 2015)

Single Photon Emission Computed Tomography (SPECT) (rvsd2015)

Skeletal Manipulation under Anesthesia (rvsd 2016)

Sleep-Disordered Breathing Testing (rvsd 2011)

SpeechTherapy (rvsd 2015)

Spinal Fusion Surgery 2105 (new 2015).pdf

Spinal Fusion Surgery 2105 (new 2015).pdf

State-Mandated Early Intervention System (EIS) (rvwd 2015)

Stereotactic Radiosurgery and Radiotherapy (rvsd2015)

Sural Nerve Graft with Radical Prostatectomy (rvwd 2016)

Testosterone Replacement (new2015)

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

Thermal Annular and Intradiscal Thermalablation Procedures (rvwd 2015)

Thyrogen (rvsd 2016)

Topographic Genotyping (PathFinder TG) (rvwd 2014)

Transcranial Magnetic Stimulation (rvsd 2016)

Transvaginal Ultrasonography (non-obstetrical) (rvwd 2014)

Trigger Point Injections (rvsd 2016)

Tumor Chemotherapy Sensitivity and Resistance Assays (rvsd 2015)

Umbilical Cord Blood Banking (rvsd2014)

Vacuum Assisted Negative Pressure Wound Therapy (rvsd 2016)

Varicose Vein Interventions (Lower Extremities) (rvsd 2016)

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

Video and Ambulatory EEG Monitoring (rvsd 2016)

Vitamin B-12 Therapy (injectable) (rvsd 2015)

Weight Loss Treatment (non-surgical) (rvsd 2016)

Wellness Benefits Adult and Pediatric (rvwd 2016)

Whole Body Cutaneous Photography (WBCP) (rvsd 2016)

Wigs (rvsd 2015)

Wireless Capsule Endoscopy (rvsd 2014)

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