Medical Policy
Download PDF versions of Capital Health Plan's Medical Policies.
| Clinical Criteria (Non-Medication) Updated 05/10/2013 | Commercial | Medicare |
| Anesthesia and Facility Charges for Dental Services | PDF (pdf 35.78 kB) | PDF (pdf 30.92 kB) |
| Artificial Cervical Disc Replacement | PDF (pdf 36.90 kB) | |
| Autism Spectrum Disorders Treatment | PDF (pdf 546.37 kB) | |
| Back and Neck Surgeries | PDF (pdf 151.93 kB) | |
| Back and Neck Surgery Devices | PDF (pdf 59.36 kB) | |
| Blepharoplasty/Ptosis Repair Surgery | PDF (pdf 353.06 kB) | PDF (pdf 27.92 kB) |
| Breast Reduction Surgery | PDF (pdf 30.31 kB) | PDF (pdf 28.16 kB) |
| Colonoscopies | PDF (pdf 74.31 kB) | |
| Computed Tomographic Colonography (aka Virtual Colonoscopy or CT Colonoscopy) | PDF (pdf 42.34 kB) | PDF (pdf 27.76 kB) |
| Cosmetic Services | PDF (pdf 31.84 kB) | |
| Dental Extractions for Head and Neck Radiation Treatments and Deep Space Neck Infections | PDF (pdf 35.52 kB) | PDF (pdf 35.09 kB) |
| Enteral Formula and Pumps for Enteral Feeding | PDF (pdf 29.51 kB) | PDF (pdf 29.80 kB) |
| Hyperbaric Oxygen Therapy | PDF (pdf 902.30 kB) | PDF (pdf 44.47 kB) |
| Implantable Hearing Devices | PDF (PDF 478.89 kB) | PDF (pdf 31.82 kB) |
| Insulin Pump User Selection | PDF (pdf 483.09 kB) | PDF (pdf 28.08 kB) |
| Kyphoplasty | PDF (pdf 33.84 kB) | PDF (pdf 33.91 kB) |
| Knee Replacement and Hip Replacement Surgery Comorbidity | PDF (pdf 66.44 kB) | PDF (pdf 66.44 kB) |
| Lumbar Spinal Fusion | PDF (pdf 27.72 kB) | |
| MRI Cervical Spine Outpatient | PDF (pdf 79.66 kB) | PDF (pdf 27.87 kB) |
| MRI Knee Outpatient | PDF (pdf 35.16 kB) | PDF (pdf 35.16 kB) |
| MRI Lumbar Spine Outpatient | PDF (pdf 114.05 kB) | PDF (pdf 27.79 kB) |
| Negative Pressure Wound Therapy Pump | PDF (pdf 503.27 kB) | PDF (pdf 34.26 kB) |
| Nurse Approval of Authorizations/Services | PDF (pdf 32.46 kB) | PDF (pdf 31.91 kB) |
| Oncotype DX Testing | PDF (pdf 663.16 kB) | PDF (pdf 27.89 kB) |
| Osteogenesis Stimulators | PDF (pdf 31.94 kB) | PDF (pdf 28.38 kB) |
| Ostomy Supplies | PDF (pdf 45.82 kB) | PDF (pdf 45.90 kB) |
| Panniculectomy and Abdominoplasty | PDF (pdf 43.23 kB) | PDF (pdf 43.43 kB) |
| Partial Hospitalization Program for Substance Abuse Treatment | PDF (pdf 33.71 kB) | PDF (pdf 27.90 kB) |
| Power Wheelchairs | PDF (pdf 1.02 MB) | PDF (pdf 27.86 kB) |
| Residential Eating Disorders Treatment | PDF (pdf 33.34 kB) | PDF (pdf 33.60 kB) |
| Residential Substance Abuse Treatment | PDF (pdf 32.20 kB) | PDF (pdf 27.58 kB) |
| Respiratory Assist Devices | PDF (pdf 92.01 kB) | PDF (pdf 28.00 kB) |
| Rhinoplasty | PDF (pdf 31.28 kB) | PDF (pdf 31.29 kB) |
| Seat Lift Mechanisms | PDF (pdf 33.91 kB) | PDF (pdf 33.68 kB) |
| Skilled Nursing Facilities | PDF (pdf 44.22 kB) | PDF (pdf 44.14 kB) |
| Sleep Studies | PDF (pdf 30.42 kB) | PDF (pdf 27.09 kB) |
| Speech Generating Devices | PDF (pdf 41.12 kB) | PDF (pdf 36.38 kB) |
| Spinal Cord Stimulator | PDF (pdf 33.58 kB) | PDF (pdf 33.70 kB) |
| Surgical Treatment of Morbid Obesity | PDF (pdf 37.99 kB) | PDF (pdf 38.42 kB) |
| TMH Bariatric Center | PDF (pdf 73.68 kB) | |
| Vertebroplasty, Percutaneous | PDF (pdf 33.19 kB) | PDF (pdf 33.68 kB) |
| Wound Treatment Centers | PDF (pdf 27.62 kB) | PDF (pdf 27.62 kB) |