Clinical Policies
Keystone First is dedicated to providing the most comprehensive, outcomes-driven health solutions for our members. Part of this approach means making it a priority to reduce unnecessary variations in care. We've used the latest scientific evidence and research to create the clinical policies, which represent the latest in current professional standards.
While these guidelines are intended to inform, they aren't intended to replace a physician's clinical judgment. The physician remains responsible for determining the applicable treatment for each individual.
Navigate directly to a letter:
-
A
- Acoustic cardiography/heart sound recording
- Actigraphy
- Acupuncture
- Air ambulance transport
- Altered auditory feedback devices for speech dysfluency (stuttering)
- Ambulatory blood pressure monitoring
- Apnea monitors for infants-in home use
- Aquatic therapy
- Athletic pubalgia (sports hernia) surgery
- Auricular stimulation for abdominal pain from irritable bowel syndrome
- Automated scalp cooling
-
B
- Balloon dilation of the Eustachian tube
- Biofeedback for chronic pain
- Bioimpedance devices for detecting lymphedema
- Blue Native polyacrylamide gel electrophoresis for mitochondrial myopathies
- Bone graft substitutes
- Bone marrow transplant for children with hyper IgM disorder
- Brachytherapy for cancers other than prostate
- Breast pumps
- Bronchial thermoplasty for severe asthma
-
C
- Cecostomy for fecal incontinence
- Cervical traction devices for neck pain for home use
- Chromosomal microarray analysis in prenatal and postnatal care
- Chronic inflammatory response syndrome
- Computer-aided detection and diagnosis for chest imaging
- Computerized gait analysis
- Core decompression for avascular necrosis of the hip
- Corneal cross-linking
- Coronary intravascular lithotripsy
- Cryopreservation of reproductive tissue, gametes, and embryos
- Customized lymphedema garments
-
D
- Dermabrasion and chemical peel
- Digestive enzyme cartridge
- Disposable insulin delivery devices
- Drug-eluting sinus implants
- Dynamic movement orthoses (suit therapy)
- Dynamic splinting
-
E
- Electrical muscle stimulation
- Embrace 2 watch for seizure detection.
- Emerg Auto-Emersion Therapy system and Dolphin Fluid Immersion Simulation system for pressure injury
- EndeavorRx video for ADHD
- Epidermal nerve fiber density testing
- Equine-assisted therapy
- Erectile dysfunction treatments other than pharmaceuticals
- Excimer laser for vitiligo
-
F
- Face transplantation
- Fetal surgeries in utero
- Fluorescence in situ hybridization for cervical cancer screening
- Fluorescence spectroscopy for prostate cancer diagnosis
- Frenuloplasty for ankyloglossia
-
G
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H
- Hand and arm transplants
- Home uterine activity monitoring
- Home-use light box therapy for seasonal affective disorder
- Hydrogel spacer use during radiotherapy for prostate cancer
- Hypoglossal nerve stimulation
-
I
- IFuse implant system
- Immune cell function assays in transplantation
- Inhaled nitric oxide
- Injectable bulking agents — fecal incontinence
- Intermittent pneumatic compression for peripheral artery disease
- Intracranial hypertension stent
- Intravascular ultrasound
-
K
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L
- Laser thermal ablation for seizures refractory to medical management
- Latera absorbable nasal implant
- Lipoprotein apheresis
- Low-frequency ultrasound therapy for wound management
- Lung transplants
-
M
- MarginProbe®
- Measurement of serum antibodies to Infliximab and Adalimumab
- Medical alert devices
- Medical three-dimensional printing
- Microwave thermotherapy for breast cancer
- Myocardial strain imaging
-
N
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O
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P
- Pancreas transplantation
- Pediatric bed enclosures and sensory beds
- Pediatric rhinoplasty
- Percutaneous arteriovenous fistula creation using EverlinQ and Ellipsys techniques
- Percutaneous sacroplasty
- Peripheral nerve stimulators for chronic nerve pain
- Peristeen® anal irrigation system
- Peroral endoscopic myotomy
- Phototherapy and photochemotherapy for skin conditions
- Phrenic (diaphragmatic) nerve stimulation
- Plastic reconstructive surgery
- Platelet rich plasma for nonhealing diabetic wounds
- Port-wine stain and infantile hemangioma treatment
- Postural orthostatic tachycardia syndrome — physical therapy
- Prescription digital therapeuticss for contraception
- Prolotherapy
-
R
- Radiofrequency ablation for nasal valve collapse
- Radiofrequency ablation of genicular nerves for knee pain
- Renal denervation
- Robotic orthoses – lower limb
- Robotic orthoses – upper limb
- Room humidifiers
-
S
- Sacral nerve modulation/stimulation
- Scoliosis vertebral body tethering and stapling
- Shoe lifts for leg length discrepancy
- Sialendoscopy and lithotripsy for salivary stones
- Skin surgery after massive weight loss
- Smell and taste dysfunction testing
- Specialized infant formula
- Speech therapy
- Stereotactic navigation in sinus surgery
- Supraglottoplasty and laryngoplasty
-
T
- Tactile breast imaging
- Therapeutic contact lenses
- Three-dimensional imaging and interpretation
- Topical oxygen therapy
- Total artificial heart
- Transanal radiofrequency for fecal incontinence
- Transcatheter coronary infusion of supersaturated oxygen therapy in acute myocardial infarction
-
V
- Vaginitis diagnostic testing
- Vagus nerve stimulation for post-stroke upper limb rehabilitation
- Vestibular evoked myogenic potential testing
- Video head impulse testing
- Virtual colonoscopy – CT colonography
- Volatile organic compounds for urinary tract infection
-
W
- Wearable dialysis and implantable artificial kidneys
- Wheelchair mounted robotic arm – Kinova Jaco2
- Wireless pulmonary artery pressure monitoring devices for heart failure
-
X
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