Clinical

Clinical Policies

The policies below summarize BMC HealthNet Plan's clinical coverage criteria for specific clinical services. These policies are used as a guide by the Plan's professional staff for clinical determinations in connection with health care coverage decisions. Clinical coverage criteria policies address new technology, treatment approaches and diagnostic and therapeutic procedures. Medical technology is continuously evolving, and the Plan's clinical coverage undergoes regular updates.

Benefits and eligibility are determined before clinical coverage policies are applied to any claim. As a result, adherence to these clinical policies does not guarantee payment when a member is ineligible or a non-covered benefit is rendered.

The definitions used throughout these policy statements have been centralized into a single location. These may be accessed through the below link:

• Actigraphy Testing 
• Ambulance and Transportation Services 
• Ambulatory Cardiac Event Monitors 
• AND Policy 
• Autism Sprectum Disorders Medical Diagnosis and Treatment 
• Balloon Sinuplasty
• Bariatric Surgery
• Breast-Reconstruction 
• Breast Reduction Mammoplasty in Females 
• Biofeedback for Urinary Incontinence 
• Capsule Endoscopy 
• Cardiac Rehabilitation 
• Central Auditory Processing Disorder Testing 
• Cervical and Lumbar Artificial Disc Replacement
• Clinical Trials 
• Cochlear Implants and BAHA 
• Complementary and Alternative Medicine 
• Computer Assisted Navigation Orthopedic Procedures 
• Contact Lens 
• Continuous Glucose Monitoring Systems 
• Cosmetic, Reconstructive, and Restorative Services 
• Endoscopic Treatments for GERD 
• Experimental and Investigational Treatment 
• Facet Joint Nerve Injections and Sacroiliac Joing Injections for Chronic Neck and Back Pain 
• Gastric Electrical Stimulation 
• Genetic Testing 
• Genetic Testing for Breast and Ovarian Cancer
• Genetic Testing for Colorectal Cancer 
• Genetic Testing for Fragile X Syndrome
• Genetic Testing for Susceptibility to Melanoma
• Hippotherapy 
• Home Health Care Guidelines 
• Home Prothrombin Time Monitors 
• Hyperbaric Oxygen Therapy
• IMRT 
• Infertility Services 
• Long Term Video Electroencephalography (EEG) Monitoring 
• Mastopexy 
• Mechanized Spinal Distraction Therapy
• Medically Necessary Hospital Services Non-Covered Dental Services 
• Medical Necessity 
• Medical Nutrition Therapy in the Outpatient or Office Setting 
• Medical Respite 
• Mobile Outpatient Cardiac Telemetry (MCOT)
• Nerve Repairs for Peripheral Nerve Injuries Using Conduits, Allografts and Autografts 
• Occupational Therapy Guidelines in the Outpatient Setting
• Oncotype DXTM Gene Expression Profiling of Tumor Tissue to Predict Breast Cancer Recurrence 
• Osteochondral Treatments for Defects of the Knee 
• Pancreas Kidney Transplant 
• Pectus Excavatum Surgery 
• Pelvic Floor Sacral Nerve Stimulation for Urinary Incontinence
• PGD 
• Phototherapy and Photochemotherapy for Dermatological Conditions Excluding Treatment for Newborn Jaundice 
• Physical Therapy Guidelines in the Outpatient Setting
• Prolotherapy 
• Pulmonary Rehabilitation in the Outpatient Setting
• Pulmonary Rehabilitation Effective 07-01-12
• Radiofrequency Facet Denervation for Back Pain 
• Redundant Skin Surgery Procedures
• Skin Substitutes for Wound Healing  
• Speech, Language, Swallowing, or Voice Therapy for Adults over the Age of 21 Years in the Outpatient Setting 
• Speech, Language, Swallowing, Feeding or Voice Therapy for Children Under the Age of 21 Years in the Outpatient Setting 
• Spinal Cord and Occiptial Nerve Stimulatio for Chronic Pain
• Surgical Treatment for Male Gynecomastia 
• Temporamandibular Joint Disorder Treatment 
• Thermal Intradiscal and Other Minimally Invasive Surgical Treatments for Back Pain 
• TMJ DisorderTreatment 
• Transoral Incisionless Fundoplication EsophyX for GERD 
• Transplant Lung 
• Transplant Pancreas Alone, Pancreas-Kidney, or Pancreas Islet Cell 
• Transplant Small Bowel and Multivisceral in Adults and Children 
• Tube Fed Enteral Nutrition
• Vagus Nerve Stimulation 
• Vision Therapy 
• Vision Therapy-Effective 07-01-12 
• Whole Body Photography