Medical Policy

Download pdf versions of Capital Health Plan's Medical Policies.

Clinical Criteria (Non-Medication) Updated 5/4/2012 Commercial Medicare
Anesthesia and Facility Charges for Dental Services PDF (pdf 56.57 kB) PDF (pdf 31.54 kB)
Artificial Cervical Disc Replacement PDF (pdf 40.74 kB)  
Artificial Lumber Disc Replacement PDF (pdf 38.64 kB)  
Autism Spectrum Disorders Treatment PDF (pdf 591.32 kB)  
Back and Neck Surgeries PDF (pdf 182.70 kB) PDF (pdf 63.26 kB)
Blepharoplasty/Ptosis Repair Surgery PDF (pdf 431.48 kB) PDF (doc 76.00 kB)
Breast Reduction Surgery PDF (pdf 30.44 kB) PDF (pdf 28.60 kB)
Colonoscopies PDF (pdf 128.92 kB) PDF (pdf 128.95 kB)
Computed Tomographic Colonography (aka Virtual Colonoscopy or CT Colonoscopy) PDF (pdf 55.97 kB) PDF (doc 76.50 kB)
Cosmetic Services PDF (pdf 37.18 kB)  
Dental Extractions for Head and Neck Radiation Treatments and Deep Space Neck Infections PDF (pdf 44.14 kB) PDF (pdf 43.94 kB)
Enteral Formula and Pumps for Enteral Feeding PDF (pdf 29.52 kB) PDF (pdf 29.95 kB)
Hyperbaric Oxygen Therapy PDF (pdf 925.23 kB) PDF (doc 81.00 kB)
Insulin Pump User Selection PDF (pdf 605.25 kB) PDF (doc 82.50 kB)
Kyphoplasty PDF (pdf 53.94 kB) PDF (pdf 37.39 kB)
Knee Replacement and Hip Replacement Surgeries PDF (pdf 85.83 kB) PDF (pdf 85.83 kB)
MRI Cervical Spine Outpatient PDF (pdf 89.16 kB) PDF (doc 76.50 kB)
MRI Knee Outpatient PDF (pdf 39.73 kB) PDF (pdf 39.70 kB)
MRI Lumbar Spine Outpatient PDF (pdf 123.53 kB) PDF (doc 76.50 kB)
Negative Pressure Wound Therapy Pump PDF (pdf 531.97 kB) PDF (pdf 34.29 kB)
Nurse Approval of Authorizations/Services PDF (pdf 36.82 kB) PDF (pdf 36.67 kB)
Oncotype DX Testing PDF (pdf 818.59 kB) PDF (pdf 36.22 kB)
Osteogenesis Stimulators PDF (pdf 32.08 kB) PDF (doc 76.50 kB)
Ostomy Supplies PDF (pdf 55.44 kB) PDF (pdf 55.63 kB)
Panniculectomy and Abdominoplasty PDF (pdf 55.33 kB) PDF (pdf 55.32 kB)
Partial Hospitalization Program for Substance Abuse Treatment PDF (pdf 43.49 kB) PDF (pdf 93.54 kB)
Power Wheelchairs PDF (pdf 1.25 MB) PDF (doc 76.00 kB)
Residential Eating Disorders Treatment PDF (pdf 37.12 kB) PDF (pdf 37.25 kB)
Residential Substance Abuse Treatment PDF (pdf 40.76 kB) PDF (pdf 91.92 kB)
Respiratory Assist Devices PDF (pdf 98.65 kB) PDF (doc 87.00 kB)
Rhinoplasty PDF (pdf 35.19 kB) PDF (pdf 35.28 kB)
Seat Lift Mechanisms PDF (pdf 37.29 kB) PDF (pdf 37.32 kB)
Skilled Nursing Facilities PDF (pdf 48.41 kB) PDF (pdf 48.36 kB)
Sleep Studies PDF (pdf 51.25 kB) PDF (pdf 27.49 kB)
Speech Generating Devices PDF (pdf 49.20 kB) PDF (pdf 39.99 kB)
Spinal Cord Stimulator PDF (pdf 37.76 kB) PDF (pdf 37.86 kB)
Surgical Treatment of Morbid Obesity PDF (pdf 43.33 kB) PDF (pdf 43.79 kB)
TMH Bariatric Center PDF (pdf 35.98 kB) PDF (pdf 35.95 kB)
Vertebroplasty, Percutaneous PDF (pdf 37.05 kB) PDF (pdf 37.23 kB)