Asuris medical policies are evidence-based and take into account the available scientific evidence published in peer-reviewed journals, as well as evidence-based clinical practice guidelines and specialty society statements. The process for Asuris medical policy development is described in the Introduction to the Asuris Medical Policy Manual.
In addition, Asuris values the experience and opinions of practicing physicians and other health care providers. Your feedback on our policies is welcome and is an important part of our annual policy review process.
You may provide feedback to us on the following policies by:
- Responding to the email that directed you to this page. Please be sure to identify the policy you are providing comments on in your email response.
Contacting Medical Policy Staff. Please be sure to identify the policy in the policy name field, as well as your name, specialty and contact information. (Note: contact information only needs to be included if you do not regularly receive medical policy email notification from Asuris.)
Allergy - (1)
- Allergy and Sensitivity Tests of Uncertain Efficacy, Laboratory #01
Anesthesiology - (1)
- Quantitative Sensory Testing, Medicine #91
Anesthesiology – Pain Management - (3)
- Quantitative Sensory Testing, Medicine #91
- Sphenopalatine Ganglion Block for Headache and Pain, Medicine #160
- Sacroiliac Joint Fusion, Surgery #193
Bariatric - (1)
- Surgical Treatments for Lymphedema and Lipedema, Surgery #220
Behavioral Health - (1)
- Substance use Disorder, Behavioral Health #35
Cardiology - (7)
- Genotyping for Single Nucleotide Variants to Predict Risk of Cardiovascular Disease or Aneurysm, Genetic Testing #62
- Genetic Testing for Heritable Disorders of Connective Tissue, Genetic Testing #77
- Laboratory Tests for Organ Transplant Rejection, Laboratory #51
- Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk, Laboratory #63
- Hyperoxemic Reperfusion Therapy, Medicine #173
- Surgical Ventricular Restoration, Surgery #149
- Transcatheter Heart Valve Procedures other than Aortic Valve Implantation for Aortic Stenosis or Mitral Valve Repair, Surgery #221
Chiropractic - (1)
- Quantitative Sensory Testing, Medicine #91
Dentistry - (2)
- Dental and Orthodontic Treatment for Craniofacial Anomalies, Allied Health #33
- Genetic Testing for Heritable Disorders of Connective Tissue, Genetic Testing #77
Dermatology - (3)
- Electrical Stimulation for the Treatment of Wounds, Durable Medical Equipment #83.09
- Genetic Testing for Heritable Disorders of Connective Tissue, Genetic Testing #77
- Skin Lesion Imaging and Spectroscopy, Medicine #174
Endocrinology - (2)
- Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment, Durable Medical Equipment #75
- Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover, Laboratory #23
ENT - (5)
- Dental and Orthodontic Treatment for Craniofacial Anomalies, Allied Health #33
- Allergy and Sensitivity Tests of Uncertain Efficacy, Laboratory #01
- Sphenopalatine Ganglion Block for Headache and Pain, Medicine #160
- Phrenic Nerve Stimulation for Central Sleep Apnea, Surgery #212
- Hypoglossal Nerve Stimulation, Surtery #215
Gastroenterology - (9)
- Enteral and Oral Nutrition Therapy in the Home Setting, Allied Health #05
- Genetic Testing for Heritable Disorders of Connective Tissue, Genetic Testing #77
- Identification of Microorganisms Using Nucleic Acid Probes, Genetic Testing #85
- Serologic Genetic and Molecular Screening for Colorectal Cancer, Genetic Testing #86
- Multianalyte Assays with Algorithmic Analysis for the Evaluation and Monitoring of Patients with Chronic Liver Disease, Laboratory #47
- Confocal Laser Endomicroscopy, Medicine #151
- Magnetic Resonance Spectroscopy, Radiology #27
- Plugs for Enteric and Anorectal Fistula Repair, Surgery #175
- Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia, Surgery #196
General Surgery - (12)
- Definitive Lower Limb Prostheses, Durable Medical Equipment #18
- Bioimpedance Devices for Detection and Management of Lymphedema, Durable Medical Equipment #82
- Electrical Stimulation for the Treatment of Wounds, Durable Medical Equipment #83.09
- Reduction Mammaplasty, Surgery #60
- Surgical Ventricular Restoration, Surgery #149
- Percutaneous Axial Lumbosacral Interbody Fusion (LIF), Surgery #157
- Plugs for Enteric and Anorectal Fistula Repair, Surgery #175
- Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia, Surgery #196
- Hysterectomy, Surgery #218
- Surgical Treatments for Lymphedema and Lipedema, Surgery #220
- Transcatheter Heart Valve Procedures other than Aortic Valve Implantation for Aortic Stenosis or Mitral Valve Repair, Surgery #221
- Focal Laser Ablation of Prostate Cancer, Surgery #222
Genetics - (8)
- Single-nucleotide Variants (SNVs) to Predict Risk of Nonfamilial Breast Cancer, Genetic Testing #23
- Genetic Testing for Alpha-1 Antitrypsin Deficiency, Genetic Testing #61
- Genotyping for Single Nucleotide Variants to Predict Risk of Cardiovascular Disease or Aneurysm, Genetic Testing #62
- Genetic Testing for PTEN Hamartoma Tumor Syndrome, Genetic Testing #63
- Evaluating the Utility of Genetic Panels, Genetic Testing #64
- Genetic Testing for Rett Syndrome, Genetic Testing #68
- Genetic Testing for Macular Degeneration, Genetic Testing #75
- Genetic Testing for Heritable Disorders of Connective Tissue, Genetic Testing #77
Hematology Oncology - (4)
- BRAF Genetic Testing To Select Melanoma or Glioma Patients for Targeted Therapy, Genetic Testing #41
- Charged-Particle (Proton) Radiotherapy, Medicine #49
- Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE), Medicine #140
- Percutaneous Neuromodulation Therapy (PNT) and Percutaneous Electrical Nerve Stimulation (PENS), Surgery #44
Infectious Disease - (1)
Naturopath - (1)
- Evaluating the Utility of Genetic Panels, Genetic Testing #64
Nephrology - (1)
- Radiofrequency and Ultrasound Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension, Surgery #235
Neurology - (6)
- Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment, Durable Medical Equipment #75
- Genetic Testing for Rett Syndrome, Genetic Testing #68
- Biochemical and Cellular Markers of Alzheimer’s Disease, Laboratory #22
- Quantitative Sensory Testing, Medicine #91
- Low-Level Laser Therapy, Medicine #105
- Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation, Surgery #205
Neurosurgery - (10)
- Low-Level Laser Therapy, Medicine #105
- Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty), Surgery #131
- Dynamic Stabilization of the Spine, Surgery #143
- Automated Percutaneous and Percutaneous Endoscopic Discectomy, Surgery #145
- Interspinous and Interlaminar Stabilization and Distraction Devices (Spacers), Surgery #155
- Percutaneous Axial Lumbosacral Interbody Fusion (LIF), Surgery #157
- Total Facet Arthroplasty, Surgery #171
- Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation, Surgery #205
- Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites, Surgery #213
- Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites, Surgery #214
Obstetrics and Gynecology - (7)
- Evaluating the Utility of Genetic Panels, Genetic Testing #64
- Fetal RHD Genotyping Using Maternal Plasma, Genetic Testing #74
- Genetic Testing for Heritable Disorders of Connective Tissue, Genetic Testing #77
- Reduction Mammaplasty, Surgery #60
- Plugs for Enteric and Anorectal Fistula Repair, Surgery #175
- Hysterectomy, Surgery #218
- Uterus Transplant, Transplant #19
Oncology - (8)
- Single-nucleotide Variants (SNVs) to Predict Risk of Nonfamilial Breast Cancer, Genetic Testing #23
- Genetic Testing for PTEN Hamartoma Tumor Syndrome, Genetic Testing #63
- Evaluating the Utility of Genetic Panels, Genetic Testing #64
- Confocal Laser Endomicroscopy, Medicine #151
- Reduction Mammaplasty, Surgery #60
- Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites, Surgery #213
- Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites, Surgery #214
- Focal Laser Ablation of Prostate Cancer, Surgery #222
Ophthalmology - (4)
- Genetic Testing for Macular Degeneration, Genetic Testing #75
- Optical Coherence Tomography (OCT) of the Anterior Eye Segment, Medicine #133
- Retinal Prosthesis, Surgery #194
- Laser Trabeculotomy and Trabeculostomy, Surgery #227
Oral Surgeons - (2)
- Dental and Orthodontic Treatment for Craniofacial Anomalies, Allied Health #33
- Prefabricated Oral Appliances for Obstructive Sleep Apnea, Allied Health #36
Orthopedics - (18)
- Cooling Devices Used in the Home Setting, Durable Medical Equipment #07
- Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment, Durable Medical Equipment #75
- Myoelectric Prosthetic and Orthotic Components for the Upper Limb, Durable Medical Equipment #80
- Bioimpedance Devices for Detection and Management of Lymphedema, Durable Medical Equipment #82
- Electrical Stimulation for the Treatment of Arthritis, Durable Medical Equipment #83.10
- Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover, Laboratory #23
- Quantitative Sensory Testing, Medicine #91
- Low-Level Laser Therapy, Medicine #105
- Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions(href: "https://beonbrand.getbynder.com/m/7a320e489fe2ce85/” target: “_blank”), Surgery #87
- Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty), Surgery #131
- Automated Percutaneous and Percutaneous Endoscopic Discectomy, Surgery #145
- Interspinous and Interlaminar Stabilization and Distraction Devices (Spacers), Surgery #155
- Percutaneous Axial Lumbosacral Interbody Fusion (LIF), Surgery #157
- Vertical Expandable Prosthetic Titanium Rib, Surgery #159
- Total Facet Arthroplasty, Surgery #171
- Sacroiliac Joint Fusion, Surgery #193
- Subacromial Balloon Placement, Surgery #226
- Surgical Site of Service – Hospital Outpatient, Utilization Management #19
Pediatric Surgery - (2)
- Dental and Orthodontic Treatment for Craniofacial Anomalies, Allied Health #33
- Vertical Expandable Prosthetic Titanium Rib, Surgery #159
Pediatrics - (5)
- Enteral and Oral Nutrition Therapy in the Home Setting, Allied Health #05
- Dental and Orthodontic Treatment for Craniofacial Anomalies, Allied Health #33
- Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment, Durable Medical Equipment #75
- Genetic Testing for Heritable Disorders of Connective Tissue, Genetic Testing #77
- Vertical Expandable Prosthetic Titanium Rib, Surgery #159
Physiatry - (2)
- Definitive Lower Limb Prostheses, Durable Medical Equipment #18
- Noninvasive Ventilators in the Home Setting, Durable Medical Equipment #87
Physical Medicine - (8)
- Cooling Devices Used in the Home Setting, Durable Medical Equipment #07
- Power Wheelchairs: Group 3, Durable Medical Equipment #37
- Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment, Durable Medical Equipment #75
- Myoelectric Prosthetic and Orthotic Components for the Upper Limb, Durable Medical Equipment #80
- Bioimpedance Devices for Detection and Management of Lymphedema, Durable Medical Equipment #82
- Electrical Stimulation for the Treatment of Wounds, Durable Medical Equipment #83.09
- Quantitative Sensory Testing, Medicine #91
- Low-Level Laser Therapy, Medicine #105
- Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation, Surgery #205
Plastic Surgery - (13)
- Dental and Orthodontic Treatment for Craniofacial Anomalies, Allied Health #33
- Hyperoxemic Reperfusion Therapy, Surgery #12
- Panniculectomy, Surgery #12.01
- Pectus Excavatum and Carinatum Surgery, Surgery #12.02
- Ventral (Including Incisional) Hernia Repair, Surgery #12.03
- Dermabrasion or Microdermabrasion, Surgery #12.04
- Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair, Surgery #12.05
- Mastectomy as a Treatment of Gynecomastia, Surgery #12.06
- Rhinoplasty, Surgery #12.28
- Laser Treatment for Port Wine Stains, Surgery #12.34
- Chemical Peels, Surgery #12.50
- Reduction Mammaplasty, Surgery #60
- Surgical Treatments for Lymphedema and Lipedema, Surgery #220
Podiatry - (2)
- Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions(href: "https://beonbrand.getbynder.com/m/7a320e489fe2ce85/” target: “_blank”), Surgery #87
- Surgical Site of Service – Hospital Outpatient, Utilization Management #19
Primary Care - (34)
- Enteral and Oral Nutrition Therapy in the Home Setting, Allied Health #05
- Cooling Devices Used in the Home Setting, Durable Medical Equipment #07
- Definitive Lower Limb Prostheses, Durable Medical Equipment #18
- Power Wheelchairs: Group 3, Durable Medical Equipment #37
- Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment, Durable Medical Equipment #75
- Myoelectric Prosthetic and Orthotic Components for the Upper Limb, Durable Medical Equipment #80
- Bioimpedance Devices for Detection and Management of Lymphedema, Durable Medical Equipment #82
- Electrical Stimulation for the Treatment of Wounds, Durable Medical Equipment #83.09
- Electrical Stimulation for the Treatment of Arthritis, Durable Medical Equipment #83.10
- Genetic Testing for Alpha-1 Antitrypsin Deficiency, Genetic Testing #61
- Evaluating the Utility of Genetic Panels, Genetic Testing #64
- Identification of Microorganisms Using Nucleic Acid Probes, Genetic Testing #85
- Serologic Genetic and Molecular Screening for Colorectal Cancer, Genetic Testing #86
- Biochemical and Cellular Markers of Alzheimer’s Disease, Laboratory #22
- Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover, Laboratory #23
- Multianalyte Assays with Algorithmic Analysis for the Evaluation and Monitoring of Patients with Chronic Liver Disease, Laboratory #47
- Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk, Laboratory #63
- Quantitative Sensory Testing, Medicine #91
- Low-Level Laser Therapy, Medicine #105
- Sphenopalatine Ganglion Block for Headache and Pain, Medicine #160
- Whole Body Dual X-ray Absorptiometry (DXA) to Determine Body Composition, Radiology #41
- Hyperoxemic Reperfusion Therapy, Surgery #12
- Panniculectomy, Surgery #12.01
- Pectus Excavatum and Carinatum Surgery, Surgery #12.02
- Ventral (Including Incisional) Hernia Repair, Surgery #12.03
- Dermabrasion or Microdermabrasion, Surgery #12.04
- Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair, Surgery #12.05
- Mastectomy as a Treatment of Gynecomastia, Surgery #12.06
- Rhinoplasty, Surgery #12.28
- Laser Treatment for Port Wine Stains, Surgery #12.34
- Chemical Peels, Surgery #12.50
- Hysterectomy, Surgery #218
- Focal Laser Ablation of Prostate Cancer, Surgery #222
- Radiofrequency and Ultrasound Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension, Surgery #235
Psychiatry - (2)
- Substance use Disorder, Behavioral Health #35
- Evaluating the Utility of Genetic Panels, Genetic Testing #64
Pulmonology - (5)
- Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment, Durable Medical Equipment #75
- Noninvasive Ventilators in the Home Setting, Durable Medical Equipment #87
- Genetic Testing for Alpha-1 Antitrypsin Deficiency, Genetic Testing #61
- Phrenic Nerve Stimulation for Central Sleep Apnea, Surgery #212
- Hypoglossal Nerve Stimulation, Surtery #215
Radiation Oncology - (4)
- Charged-Particle (Proton) Radiotherapy, Medicine #49
- Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE), Medicine #140
- Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites, Surgery #213
- Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites, Surgery #214
Radiology - (8)
- Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE), Medicine #140
- Magnetic Resonance Spectroscopy, Radiology #27
- Whole Body CT Screening, Radiology #40
- Whole Body Dual X-ray Absorptiometry (DXA) to Determine Body Composition, Radiology #41
- Percutaneous Neuromodulation Therapy (PNT) and Percutaneous Electrical Nerve Stimulation (PENS), Surgery #44
- Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty), Surgery #131
- Dynamic Stabilization of the Spine, Surgery #143
- Automated Percutaneous and Percutaneous Endoscopic Discectomy, Surgery #145
Rehabilitation Medicine - (3)
- Definitive Lower Limb Prostheses, Durable Medical Equipment #18
- Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions(href: "https://beonbrand.getbynder.com/m/7a320e489fe2ce85/” target: “_blank”), Surgery #87
- Surgical Site of Service – Hospital Outpatient, Utilization Management #19
Rheumatology - (6)
- Electrical Stimulation for the Treatment of Arthritis, Durable Medical Equipment #83.10
- Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment, Durable Medical Equipment #75
- Multi-biomarker Disease Activity Blood Test for Rheumatoid Arthritis, Laboratory #67
- Low-Level Laser Therapy, Medicine #105
- Sacroiliac Joint Fusion, Surgery #193
- Subacromial Balloon Placement, Surgery #226
Sleep Physicians - (4)
- Prefabricated Oral Appliances for Obstructive Sleep Apnea, Allied Health #36
- Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment, Durable Medical Equipment #75
- Phrenic Nerve Stimulation for Central Sleep Apnea, Surgery #212
- Hypoglossal Nerve Stimulation, Surgery #215
Solid Organ Transplants - (1)
- Laboratory Tests for Organ Transplant Rejection, Laboratory #51
Urology - (2)
- Nerve Graft with Radical Prostatectomy, Surgery #117
- Focal Laser Ablation of Prostate Cancer, Surgery #222