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
- Afirma® thyroid FNA analysis for indeterminate thyroid nodules
- Air ambulance transport
- Altered auditory feedback devices for speech dysfluency (stuttering)
- Ambulatory blood pressure monitoring
- Apnea monitors for infants-in home use
- Aquatic therapy
- Artificial pancreas device system
- Athletic pubalgia (sports hernia) surgery
- Auricular stimulation for abdominal pain from irritable bowel syndrome
- Autologous chondrocyte implantation
-
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
- Brachytherapy for cancers other than prostate
- Bronchial thermoplasty for severe asthma
-
C
- Cecostomy for fecal incontinence
- Cell-free DNA prenatal screening
- Cervical traction devices for neck pain for home use
- Chromosomal microarray analysis
- Chronic inflammatory response syndrome
- Circulating tumor DNA and circulating tumor cells for cancer management (liquid biopsy)
- 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
- Cosmetic and plastic reconstructive surgery
- Cryopreservation of reproductive tissue, gametes, and embryos
-
D
- Dermabrasion and chemical peel
- Digestive enzyme cartridge
- Disposable insulin delivery devices
- Donor human milk
- Drug-eluting sinus implants
- Dynamic movement orthoses (suit therapy)
- Dynamic splinting
-
E
- Electrical muscle stimulation
- Embrace 2 watch for seizure detection.
- EndeavorRx video for ADHD
- Epidermal nerve fiber density testing
- Equine-assisted therapy
- Erectile dysfunction treatments other than pharmaceuticals
- Excimer laser for vitiligo
- Expanded carrier screening by genomic sequencing
-
F
- Face transplantation
- Fetal surgeries in utero
- Flexitouch® pneumatic compression devices for lymphedema after head and neck surgery
- Fluorescence in situ hybridization for cervical cancer screening
- Fluorescence spectroscopy for prostate cancer diagnosis
- Frenuloplasty for ankyloglossia
-
G
- Gastrointestinal electrical stimulation for obesity
- Gene expression profile testing for breast cancer
- Genetic testing for Alzheimer’s disease
- Genetic testing for Duchenne muscular dystrophy
- Genetic testing for G1691A polymorphism factor V Leiden
- Genetic testing for cystic fibrosis
- Genetic testing for epilepsy and seizure disorders
- Genetic testing for hereditary cancer susceptibility
- Genetic testing for hereditary cardiomyopathy
- Genetic testing for long QT syndrome
- Genetic testing for maple syrup urine disease
- Genetic testing for prostate cancer prognosis
- Genetic testing in sensorineural hearing loss
-
H
- Hand and arm transplants
- Home invasive positive pressure ventilation
- 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 assay
- 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 cancer screening
- Lung transplants
- Lymphedema garments
-
M
- MarginProbe
- Measurement of serum antibodies to Infliximab and Adalimumab
- Mechanical scalp cooling
- Medical alert devices
- Medical three-dimensional printing
- Melody™ transcatheter pulmonary valve replacement
- Microwave thermotherapy for breast cancer
- Molecular analysis for targeted therapy for breast cancer
- Molecular analysis for targeted therapy for colorectal cancer
- Molecular analysis for targeted therapy for esophageal cancer
- Molecular analysis for targeted therapy for ovarian cancer
- Molecular analysis for targeted therapy of non-small cell lung cancer
- Molecular analysis for targeted treatment for hepatobiliary cancer
- Molecular analysis for targeted treatment in cervical cancer
- Molecular analysis for treatment of primary brain tumors
- Molecular testing for sarcoma
- Myocardial strain imaging
-
N
- Neuroablation for chronic foot pain
- Noninvasive blood tests for rejection surveillance after heart transplant
- Nonpharmacologic treatments for chronic vertigo
-
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
- Pharmacogenetic testing for cardiac meds
- Phototherapy and photochemotherapy for skin conditions
- Phrenic (diaphragmatic) nerve stimulation
- Platelet rich plasma
- Port-wine stain and infantile hemangioma treatment
- Postural orthostatic tachycardia syndrome treatment with 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
- Serum proteomic cancer risk classification of indeterminate pulmonary nodules
- Shoe lifts for leg length discrepancy
- Sialendoscopy and lithotripsy for salivary stones
- Skin surgery after massive weight loss
- Smartwatch for detection of atrial fibrillation
- Smell and taste dysfunction testing
- Specialized infant formula
- Speech therapy
- Sphenopalatine ganglion block injections for headache
- 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 diagnosis
- 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
- V‐Go® disposable insulin pump
-
W
- Wearable dialysis and implantable artificial kidneys
- Wheelchair mounted robotic arm – Kinova Jaco2
- Whole genome sequencing and whole exome sequencing
- Wireless pulmonary artery pressure monitoring devices for heart failure
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X
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