Providence Health Plan (PHP), Providence Health Assurance (PHA), and Providence Health Plan Partners (PPP) Medical Policies serve as guidance for the administration of plan benefits. Medical policies do not constitute medical advice nor a guarantee of coverage. PHP, PHA, and PPP Medical Policies are reviewed annually and are based upon published, peer-reviewed scientific evidence and evidence-based clinical practice guidelines that are available as of the last policy update. PHP, PHA, and PPP reserve the right to determine the application of Medical Policies and make revisions to its Medical Policies at any time. Providers will be given 60-days’ notice of policy changes that are restrictive in nature.
The scope and availability of all plan benefits are determined in accordance with the applicable coverage agreement. Any conflict or variance between the terms of the coverage agreement and PHP, PHA, and PPP Medical Policy will be resolved in favor of the coverage agreement.
- Allergy Testing (All LOB except CMS)
- Allergy Testing (CMS Only)
- Ambulance Transport
- Anesthesia Care with Diagnostic Endoscopy
- Athletic Pubalgia Surgery
- Auricular Electrostimulation
- Autologous Fat Transfer
- Back: Artificial Intervertebral Discs
- Back: Cervical and Thoracic Spine Surgery
- Back: Discography
- Back: Epidural Steroid Injections (All LOB Except CMS)
- Back: Epidural Steroid Injections (CMS Only)
- Back: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (CMS Only)
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation (All LOB Except CMS)
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation (CMS Only)
- Back: Instrumentation and Stabilization Devices
- Back: Intradiscal Injections
- Back: Lumbar Spine Surgery
- Back: Lysis of Epidural Adhesions
- Back: Percutaneous Thermal Intradiscal Treatment for Low Back Pain (CMS only)
- Back: Percutaneous Thermal Intradiscal Treatment for Low Back Pain (All LOB except CMS)
- Back: Radiofrequency Ablation for Persistent Facet Pain (All LOB except CMS)
- Back: Sacroiliac Joint Fusion or Stabilization (All LOB Except CMS)
- Back: Sacroiliac Joint Fusion or Stabilization (CMS Only)
- Back: Vertebroplasty and Kyphoplasty (All LOB except CMS)
- Back: Vertebroplasty and Kyphoplasty (CMS Only)
- Balloon Dilation of the Sinuses or Eustachian Tubes
- Bariatric Surgery (All LOB except CMS)
- Bariatric Surgery (CMS Only)
- Blood Brain Barrier Disruption and Bypass
- Bone Growth Stimulators (All LOB except CMS)
- Bone Growth Stimulators (CMS Only)
- Breast Cancer: Focused Microwave Phased Array Thermotherapy
- Breast Cancer: Radiofrequency Ablation of Breast Tumors
- Breast Implant Removal
- Breast Reconstruction
- Breast Surgery: Reduction Mammoplasty (All LOB Except CMS)
- Breast Surgery: Reduction Mammoplasty (CMS Only)
- Bronchial Thermoplasty
- Cardiac: Disease Risk Screening (CMS Only)
- Cardiac: Disease Risk Screening (All LOB Except CMS)
- Cardiac: External Ambulatory Electrocardiography
- Cardiac: Implantable Loop Recorder
- Cardiac: Left Atrial Appendage Devices (All LOB except CMS)
- Cardiac: Left Atrial Appendage Devices (CMS Only)
- Cardiac: Percutaneous Aortic Valve Replacement for Aortic Stenosis
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR) (All LOB Except CMS)
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR) (CMS Only)
- Cardiac: Ventricular Assist (VAD.LVAD) and Artificial Heart Devices (BIVAD)
- Cefaly Device for Treatment of Migraine Headaches
- Celiac Disease Serologic Testing
- Chelation Therapy for Non Overload Conditions
- Chemoresistance and Chemosensitivity Assays
- Chiropractic Care
- Circulating Tumor Cell Assays For Cancer Management
- Clinical Trials and Devices (All Lines of Business Except CMS)
- Clinical Trials and IDE Studies (CMS Only)
- Cold Therapy and Cooling Devices in the Home Setting
- Colorectal Cancer Screening: FIT and Fecal DNA
- Compression: Bandages, Stockings, and Wraps
- Compression: Outpatient Pneumatic Devices
- Continuous Passive Motion Device in the Home Setting
- Cosmetic and Reconstructive Surgery
- Deep Brain Stimulation (All LOB Except CMS)
- Deep Brain Stimulation (CMS Only)
- Defibrillators: Automatic External (AED)
- Definition: Confined to the Home
- Definition: Experimental and Investigational
- Definition: Medical Necessity
- Definition: Mobility Assistive Equipment (MAE)
- Definition: Urgent Care (Out of Area)
- Dental Anesthesia Services
- Dental Services: Administrative Guideline (CMS Only)
- Dental Services: Administrative Guideline (All LOB Except CMS)
- Dermal Injections for the treatment of Facial Lipodystrophy Syndrome (CMS Only)
- Diabetes: APDS and Other Integrated Systems (All LOB except CMS)
- Diabetes: Artificial Pancreas Devices and Other Integrated Systems (CMS Only)
- Diabetes: Blood Glucose Monitors and Supplies
- Diabetes: Continuous Glucose Monitors (CGM) (All LOB except CMS)
- Diabetes: Continuous Glucose Monitors (CMS Only)
- Diabetes: Insulin Infusion Pumps (External and Implanted)
- Direct-to-Consumer Testing
- Drug, Botulinum Toxin Types A and B
- Durable Medical Equipment
- Electrothermal Capsular Shrinkage
- Exhaled Breath Tests (All LOB except CMS)
- Exhaled Breath Tests (CMS Only)
- Eye: Automated Evacuation of Meibomian Gland
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift (All LOB except CMS)
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift (CMS Only)
- Eye: Corneal Collagen Cross-Linking (All LOB Except CMS)
- Eye: Corneal Collagen Cross-Linking (CMS Only)
- Eye: Diabetic Retinopathy Telescreening
- Fecal Incontinence: Treatments
- Fecal Microbiota Transplantation
- Ganglion Impar Blocks
- Gastric Electrical Stimulation
- Gastroesophageal Reflux Disease: Endoscopic Treatments (All LOB Except CMS)
- Gastroesophageal Reflux Disease: Endoscopic Treatments (CMS Only)
- Gastrointestinal Ecology Profiles & Gastrointestinal Comprehensive Profiles
- Gender Affirming Interventions
- General PA Requirements: Medicare HMO POS
- General PA Requirements: PEBB Statewide and PEBB Choice
- General PA Requirements: PPO 1.19
- General PA Requirements: Standard
- General PA Requirements: PHS, Swedish, Kadlec, PacMed
- General PA Requirements: OHP
- Genetic Studies and Counseling
- Genetic Testing for BCR-ABL1 Negative Myeloproliferative Neoplasms (All LOB except CMS)
- Genetic Testing for BCR-ABL1 Negative Myeloproliferative Neoplasms (CMS Only)
- Genetic Testing: Breast Cancer Prognostic Assays (All LOB except CMS)
- Genetic Testing: Breast Cancer Prognostic Assays (CMS Only)
- Genetic Testing: CADASIL Disease (All LOB except CMS)
- Genetic Testing: CADASIL Disease (CMS Only)
- Genetic Testing: Hereditary Breast and Ovarian Cancer (All LOB except CMS)
- Genetic Testing: Hereditary Breast and Ovarian Cancer (CMS Only)
- Genetic Testing: Inherited Susceptibility to Colorectal Cancer (All LOB except CMS)
- Genetic Testing: Inherited Susceptibility to Colorectal Cancer (CMS Only)
- Genetic Testing: Inherited Thrombophilias (All LOB except CMS)
- Genetic Testing: Inherited Thrombophilias (CMS Only)
- Genetic Testing: Non-Covered Genetic Panel Tests (All LOB except CMS)
- Genetic Testing: Non-Covered Genetic Panel Tests (CMS Only)
- Genetic Testing: Pharmacogenetic Testing (All LOB except CMS)
- Genetic Testing: Pharmacogenetic Testing (CMS Only)
- Genetic Testing: Reproductive Planning and Prenatal Testing (All LOB Except CMS)
- Genetic Testing: Reproductive Planning and Prenatal Testing.(CMS Only)
- Genetic Testing: Thyroid Nodules (All LOB except CMS)
- Genetic Testing: Thyroid Nodules (CMS Only)
- Hand/Arm Artificial Myoelectric Limb
- Hearing Aids (All LOB Except CMS)
- Hearing: Cochlear Implants and Auditory Brainstem Implants (All LOB Except CMS)
- Hearing: Cochlear Implants and Auditory Brainstem Implants (CMS Only)
- Heating Pads and Heat Lamps
- Hernia Repair: Human Acellular Dermal Matrix
- Hip Arthroscopy
- Hip: Total Joint Arthroplasty (All LOB Except CMS)
- Hip Total Joint Arthroplasty (CMS Only)
- Home Oxygen Therapy for Cluster Headaches
- Hyperbaric Oxygen Therapy (All LOB Except CMS)
- Hyperbaric Oxygen Therapy (CMS Only)
- Inflammatory Bowel Disease (IBD) Serologic Testing and Therapeutic Monitoring
- Inflammatory Bowel Disease Measurement of Antibodies to Immunosuppressive Therapies
- Interferential Stimulation (IFS)
- Intraoperative Neurophysiological Testing and Monitoring
- Investigational and Non-covered Medical Technologies (All LOB except CMS)
- Investigational and Non-covered Medical Technologies (CMS Only)
- Joint Resurfacing
- Knee Braces (Functional)
- Knee: Ablative Procedures of Peripheral Nerves to Treat Knee Pain
- Knee: Autologous Chondrocyte Implantation (ACI) for Cartilaginous Defects
- Knee: Cartilaginous Defects of the Knee: Autologous Chondrocyte Implantation (ACI)
- Knee: Cartilaginous Defects: Procedures and Implants
- Knee: Meniscal Allograft Transplantation
- Knee: Osteochondral Allografts and Autografts for Cartilaginous Defects
- Knee: Total Joint Arthroplasty (All LOB Except CMS)
- Knee: Total Joint Arthroplasty (CMS Only)
- Liver Tumor Treatment
- Low-Level and High-Power Laser Therapy
- Lyme Disease
- Massage Therapy: PEBB and Providence Health and Services
- Microcurrent Electrical Nerve Stimulation (MENS)
- MR Guided Focused Ultrasound for Palliative Treatment of Bone Metastases
- Multi-spectral Digital Skin Lesion Analysis
- NanoKnife System.Irreversible Electroporation (IRE)
- Negative Pressure Wound Therapy (NPWT)
- Nerve Conduction Studies (All LOB except CMS)
- Nerve Conduction Studies (CMS only)
- Neuropsychological Testing (All LOB Except CMS)
- Neuropsychological Testing (CMS Only)
- Non-Small Cell Lung Cancer. Molecular Testing for Targeted Therapy (All LOB except CMS)
- Non-Small Cell Lung Cancer. Molecular Testing for Targeted Therapy (CMS Only)
- Occipital Nerve Stimulation
- Organ Transplantation
- Organic Acid Testing and Nutritional Panels
- Orthognathic Surgery
- Orthotic Foot Devices and Therapeutic Shoes
- Outpatient Physical Therapy (All LOB Except CMS)
- Ovarian Cancer: Multimarker Serum Testing
- Oxygen Therapy and Home Equipment
- Percutaneous Neuromodulation Therapy (PNT)
- Peroral Endoscopic Myotomy (POEM)
- PHA Medical Policy CMS Manual
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care, Other Misc Conditions (All LOB Except CMS)
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care, Other Misc Conditions (CMS Only)
- Port Wine Stain Laser Treatment
- Premature Rupture of Membranes (PROM) Testing
- Prolotherapy
- Prometheus Therapeutic Diagnostics
- Prostate: High Intensity Focused Ultrasound (All LOB Except CMS)
- Prostate: High Intensity Focused Ultrasound (CMS Only)
- Prostate: MRI-Transrectal Ultrasound Fusion Biopsy
- Prostate: Prostatic Urethral Lift
- Prostate: Protein Biomarkers and Genetic Testing (All LOB except CMS)
- Prostate: Protein Biomarkers and Genetic Testing (CMS Only)
- Prosthesis: Lower Limb
- Proton Beam Therapy
- Radiofrequency Lesioning, Cryosurgery, Cryotherapy for Plantar Fasciitis
- Rehabilitation: Mechanical Stretching Devices for Joints of the Extremities
- Rehabilitation: Acute Inpatient
- Rhinoplasty Functional (Non Cosmetic)
- Robotic Surgical Systems
- Salivary Hormone Testing (All LOB except CMS)
- Salivary Hormone Testing (CMS Only)
- Seat Lift Chair Mechanism
- Sensory Integration Therapy
- Skin Substitutes
- Sleep Apnea: Surgical Treatments
- Sleep Disorder Testing (All LOB except CMS)
- Sleep Disorder Testing (CMS Only)
- Sleep Disorder Treatment: Oral Appliances (All LOB except CMS)
- Sleep Disorder Treatment: Oral Appliances (CMS Only)
- Sleep Disorder Treatment: Positive Airway Pressure (All LOB Except CMS)
- Sleep Disorder Treatment: Positive Airway Pressure (CMS Only)
- Speech Generating Devices
- Standing Systems
- Stem Cell Therapy for Orthopedic Applications
- Stereotactic Computer Assisted Volumetric (Navigational) Procedure
- Subcutaneous Hormone Pellet Implant
- Surface Electromyography (sEMG) Testing
- Surgical Treatment for Skin Redundancy
- Surgical Treatments for Lymphedema
- Transcutaneous Electrical Nerve Stimulators (TENS) and Related Supplies
- Tumor Treatment Fields Therapy for Glioblastoma
- Urinary Dysfunction: Incontinence
- Urinary Dysfunction: Vesicoureteral Reflux Treatments
- Urine Drug Testing for Therapeutic or Substance Abuse Monitoring (All LOB Except CMS)
- Urine Drug Testing for Therapeutic or Substance Abuse Monitoring (CMS Only)
- Vagus Nerve Stimulation
- Varicose Veins (All LOB Except CMS)
- Varicose Veins (CMS Only)
- Vectra DA Test for Rheumatoid Arthritis
- Vestibular Autorotation Test
- Viscosupplementation (All LOB except CMS)
- Viscosupplementation (CMS Only)
- Vitamin D Assay Testing
- Walkers
- Wheelchairs and Power Vehicles
- Wireless Capsule Endoscopy
- Wireless Capsule for Gastrointestinal Motility Monitoring
- Wound Therapy: Negative Pressure Wound Therapy (NPWT) V.A.C Vacuum Assisted Closure
- Wounds: Non-Contact Ultrasound Treatment