The purpose of UHA Medical Payment Policies is to guide coverage decisions and to provide information regarding the need for prior authorization and other administrative directives. They are not intended to influence treatment decisions and do not constitute plan authorization. Medical necessity must be clear. They are not explanations of benefits.
Medical policies can be highly technical and complex and are provided here for informational purposes. They do not constitute medical advice. Medical technology is constantly evolving and these medical policies are subject to change without notice. Additional medical policies may also be developed from time to time and some may be withdrawn from use as science advances. Clinical context can be highly variable.
COSMETIC SERVICES
DIAGNOSTIC TESTING
DME
- Apnea Monitor for Infants
- Durable Medical Equipment
- Home Phototherapy for Neonatal Jaundice
- Insulin Pumps - External
- Negative Pressure Wound Therapy
- Oscillatory Device for Bronchial Drainage (The Vest™)
- Oxygen and Oxygen Equipment
- Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea
- Pulse Oximeter for Children
- Spinal Cord Stimulators for Pain Management
- Transcutaneous Electrical Nerve Stimulation (TENS)
FACILITY
- Ambulatory Blood Pressure Monitoring
- Endoscopic Radiofrequency Ablation for Barrett's Esophagus
- Extracorporeal Membrane Oxygenation (ECMO) for Neonates
- Implantable Ventricular Assist Devices and Total Artificial Hearts
- Intensity Modulated Radiation Therapy (IMRT)
- Kyphoplasty and Vertebroplasty
- Never Events and Hospital-Acquired Conditions
- Observation Services
- Polysomnography (Sleep Studies)
- Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
- Readmissions and Transfers
- Surgical Treatment of Femoroacetabular Impingement
- Uterine Artery Embolization to Treat Fibroids
INFUSION SERVICES
MISCELLANEOUS
- After Hours Billing
- Breast Reconstruction Surgery
- Clinical Trials
- Computerized Corneal Topography
- Emerging Technology Payment Policy
- Esophageal pH Monitoring
- Growth Hormone Therapy
- Home Health Care
- Hyperbaric Oxygen Treatment (HBO)
- Lipid Risk Factors (Novel) in Risk Assessment and Management of Cardiovascular Disease
- Medical Foods for Inborn Errors of Metabolism
- Office Visits and Consultations
- Open Access Hospice/Concurrent Care for Terminally Ill Patients
- Photochemotherapy
- Photodynamic Therapy for the Treatment of Actinic Keratoses and Other Skin Lesions
- Physician Assistants
- Telehealth / Telemedicine
OB/GYN
PRESCRIPTION DRUGS
PREVENTIVE HEALTH SERVICES
RADIOLOGY
- 3D Reconstruction Imaging Payment Policy
- Charged-Particle (Proton or Helium Ion) Radiation Therapy
- Dual Energy X-ray Absorptiometry (DEXA) Scans
- Grenz Ray Therapy Payment Policy
- Intravascular Coronary Brachytherapy Payment Policy
- Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk
- Non-coronary Brachytherapy
- Real-Time Intra-Fraction Target Tracking During Radiation Therapy
- Stereotactic Radiosurgery (SRS) and Fractionated Stereotactic Body Radiotherapy (SRBT)
- Vacuum Assisted Breast Biopsy
- Virtual (CT) Colonoscopy Payment Policy
REHABILITATIVE THERAPY
SURGERY
- Anesthesia Services for Gastrointestinal Endoscopic Procedures
- Artificial Disc Replacement
- Autologous Chondrocyte Implantation
- Bariatric Surgery
- Blepharoplasty and Repair and Blepharoptosis
- Catheter and Surgical Ablation of Atrial Fibrillation
- Carotid Artery Stenting
- Colonoscopy
- Intrastromal Corneal Ring Segments for Keratoconus
- Lung Volume Reduction
- Panniculectomy/Abdominoplasty
- Prophylactic Mastectomy
- Reduction Mammaplasty
- Thoracic Sympathectomy for Hyperhidrosis
- Tissue-Engineered Skin Substitutes
- Transcatheter Aortic-Valve Implantation for Aortic Stenosis
- Treatment of Hepatic Neoplasm
- Treatment of Prostate Cancer
- Treatment of Varicose Veins
TRANSPLANTS, SOLID ORGAN
TRANSPLANTS, STEM CELL
- Allogenic Hematopoetic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias
- Allogenic Hematopoietic Stem-Cell Transplantation for Myodysplastic Syndromes and Myeloproliferative Neoplasms
- Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas
- Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia
- Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia
- Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases
- Hematopoietic Stem-Cell Transplantation for Breast Cancer
- Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
- Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia
- Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma
- Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer
- Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma
- Hematopoietic Stem-Cell Transplantation for Multiple Myelomas
- Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas
- Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis or Waldenstrom Macroglobulinemia
- Hematopoietic Stem-Cell Transplantation for Solid Tumors in Adults
- Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
- Hematopoietic Stem-Cell Transplantation in the Treatment of Germ-Cell Tumors




