Medical policies

Below are links to the most up-to-date policies on treatment options for FCHP members. Each policy includes an overview, policy and criteria, an explanation of when services are covered, and any exclusions that apply.

• Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy (pdf, 167 KB)
• Allogeneic Stem Cell Transplant (pdf, 123 KB)
• Allograft Transplants of the Knee (pdf, 108 KB)
• Ambulatory Blood Pressure Monitoring (pdf, 59 KB)
• Anesthesia Assistance with Gastrointestinal Endoscopic Procedures (pdf, 93 KB)
• Array Comparative Genomic Hybridization (pdf, 113 KB)
• Arthroscopy for Osteoarthritis of the Knee (pdf, 76 KB)
• Autologous Blood Donation, Processing and Storage (pdf, 61 KB)
• Autologous Chondrocyte Implant (pdf, 153 KB)
• Autologous Platelet Derived Growth Factor (formerly "Autologous Platelet Derived Products") (pdf, 53 KB)
• Autologous Stem Cell Transplant (pdf, 124 KB)
• Automated External Defibrillator (non-wearable) (replaces "Automated External Defibrilator & Wearable Cardioverter Difibrilator") (pdf, 100 KB)
• Bedwetting Alarms for Nocturnal Enuresis (pdf, 65 KB)
• Biofeedback for Urinary Incontinence (pdf, 71 KB)
• Bone-Anchored Hearing Aids (pdf, 100 KB)
• Bone Growth Stimulators - Electric & Ultrasound (pdf, 79 KB)
• Breast Pumps (pdf, 56 KB)
• Cervical Artificial Disc Replacement (pdf, 77 KB)
• Chiropractic Services (pdf, 101 KB)
• Clinical Trials (pdf, 65 KB)
• Cochlear Implants (pdf, 166 KB)
• Conformal and Intensity Modulated Radiation Therapy (IMRT) of the Breast (pdf, 121 KB)
• Continuous Interstitial Glucose Monitoring (pdf, 111 KB) 
• Cornea Transplant (pdf, 57 KB)
• Cosmetic, Reconstructive, and Restorative Services (pdf, 196 KB)
• Cranial Orthotic Devices for the Treatment of Plagiocephaly (pdf, 52 KB)
• Deep Brain Stimulation (pdf, 95 KB)
• Double Balloon Enteroscopy (pdf, 89 KB)
• Durable Medical Equipment (pdf, 93 KB)
• Early Intervention Services (pdf, 61 KB)
• Extracorporeal Shock Wave Treatment (ESWT) for Chronic Plantar Fasciitis and Other Musculoskeletal Conditions (pdf, 57 KB)
• Fetal Surgery (in utero or intrauterine) (pdf, 63 KB)
• First Trimester Prenatal Screening (pdf, 95 KB)
• Genetic Testing (pdf, 239 KB)
• Heart Transplant (pdf, 68 KB)
• Heart-Lung Transplant (pdf, 68 KB)
• High Frequency Chest Wall Oscillation Vest (The Vest) (pdf, 60 KB)
• HIV-1 Co-receptor Tropism Assays (pdf, 62 KB)
• Home Prothrombin Time Testing (pdf, 110 KB)
• Hospice (pdf, 96 KB) 
• Human Papilloma Virus (HPV) DNA Testing (pdf, 54 KB)
• Hyperbaric Oxygen Therapy (pdf, 70 KB)
• Impella Percutaneous Cardiac Support System (pdf, 155 KB)
• Insulin Pumps (pdf, 56 KB)
• Interspinous Process Decompression (X-Stop®) (pdf, 85 KB)
• In Vitro Chemoresponse Assays (pdf, 84 KB)
• Kidney Transplant (pdf, 60 KB)
• Light Box Therapy for Seasonal Affective Disorder (SAD) (pdf, 49 KB)
• Liver Transplant (pdf, 77 KB)
• Lumbar Artificial Disc Replacement (pdf, 83 KB)
• Lung Transplant (pdf, 66 KB)
• Lyme Disease (pdf, 116 KB)
• Mobile Cardiac Telemetry (pdf, 67 KB)
• Neuromuscular Electrical Stimulation (pdf, 56 KB)
• Oncotype Dx^TM (pdf, 57 KB)
• Oral Retainers for Obstructive Sleep Apnea (pdf, 62 KB)
• Pancreas After Kidney (PAK) Transplant (pdf, 54 KB)
• Pap Smear/Cervical Cancer Screening (pdf, 68 KB)
• Percutaneous Vertebroplasty & Kypholplasty (or Balloon-Assisted Vertebroplasty) (pdf, 166 KB)
• Phototherapeutic Keratectomy (formerly "Photorefractive Keratectotomy") (pdf, 56 KB)  
• Posterior Tibial Nerve Stimulation (pdf, 62 KB)
• Post-mastectomy Surgery and Services (pdf, 71 KB)
• Pulse Oximeters (pdf, 49 KB)
• Pulsed Dye Laser (formerly "Tunable Dye, Pulsed Dye Laser") (pdf, 52 KB)
• Sacral Nerve Stimulation for Urinary Urge Incontinence (pdf, 55 KB)
• Simultaneous Pancreas-Kidney (SPK) Transplant (pdf, 57 KB)
• Small Bowel, Small Bowel/Liver and Multi-Visceral Transplant (pdf, 60 KB)
• Speech Generating Devices (pdf, 64 KB)
• Speech Therapy (pdf, 52 KB)
• Spinal Cord Stimulation for the Treatment of Pain (pdf, 57 KB)
• Transcutaneous Electric Nerve Stimulation (TENS) (pdf, 55 KB)
• Vagus Nerve Stimulation (pdf, 58 KB)
• Varicose Vein Treatment (pdf, 62 KB)
• Vertebral Fracture Assessment (pdf, 81 KB) 
• Virtual Colonoscopy (pdf, 91 KB)  
• Weight Loss Surgery (pdf, 148 KB)
• Wireless Capsule Endoscopy (pdf, 101 KB)