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
- Abdominoplasty
- 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
- Autoimmune disease diagnostic panel testing
- Autologous fat grafting and injectable soft-tissue fillers
- Automated scalp cooling
-
B
- Balloon Spacer Devices for Management of Massive Rotator Cuff Tears
- Balloon dilation of the Eustachian tube
- Behavioral health weight management interventions for children with increased body mass index screenings
- Biofeedback for chronic pain
- Bioimpedance spectroscopy extracellular fluid analysis
- 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
- Cardiac contractility modulation
- Cecostomy for fecal incontinence
- Cervical Traction Devices for Neck Pain for Home Use
- 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 Splinting
- Dynamic movement orthoses (suit therapy)
-
E
- Electrical muscle stimulation
- Electroretinography
- Embrace 2 watch for seizure detection
- Emerg Auto-Emersion Therapy System and Dolphin Fluid Immersion Simulation System for Pressure Injury
- Endobronchial Valve Placement
- EpiSign Testing for DNA Methylation Analysis
- Equine-Assisted Therapy
- Erectile dysfunction treatments other than pharmaceuticals
- Excimer Laser for Vitiligo
-
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
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H
- Hand and arm transplants
- Home Spirometry
- Home ultraviolet light therapy equipment for skin conditions
- Home uterine activity monitoring
- Home-use Light Box Therapy for Seasonal Affective Disorder
- Hydrogel spacer use during radiotherapy for prostate cancer
-
I
- 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 interstitial thermal therapy for drug-resistant epilepsy
- Latera Absorbable Nasal Implant
- Lipoprotein Apheresis
- Low-frequency ultrasound therapy for wound management
-
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
- Optical coherence tomography imaging of the ear
- Oral Nutritional Supplements
- Ovarian cancer serum biomarker risk assessment testing
-
P
- Pancreas transplantation
- Pediatric bed enclosures
- Pediatric gastric alimetry
- Pediatric rhinoplasty
- Percutaneous Peripheral Nerve Stimulators for Chronic Nerve Pain
- Percutaneous arteriovenous fistula creation
- Percutaneous sacroplasty
- Peristeen Transanal 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
- Prescription Digital Therapeutics For Contraception
- Prescription Digital Therapeutics for Amblyopia
- Prescription digital therapeutics for attention deficit hyperactivity disorder
- Prolotherapy
- Pulsed dye laser for port-wine stain and infantile hemangioma
-
R
- RESET-O
- Radiofrequency Ablation for Nasal Valve Collapse
- Radiofrequency ablation of genicular nerves for knee pain
- Rapid molecular infectious disease testing for Group A Streptococcus
- Renal denervation
- Robotic orthoses – lower limb
- Robotic orthoses – upper limb
- Room humidifiers
-
S
- Sacral nerve modulation/stimulation
- Scoliosis vertebral body tethering and stapling
- Serum Tests for Preeclampsia Risk Assessment
- Shoe Lifts for Leg Length Discrepancy
- Sialendoscopy and lithotripsy for salivary stones
- Skin Substitutes for Chronic Wounds
- Skin surgery after massive weight loss
- Smell and taste dysfunction testing
- Speech therapy
- Stereotactic navigation in sinus surgery
- Supraglottoplasty and Laryngoplasty
-
T
- Tactile breast imaging
- Therapeutic Contact Lenses
- Three-dimensional imaging and interpretation
- Tongue neurostimulation for snoring and mild obstructive sleep apnea
- Topical oxygen therapy
- Total artificial heart
- Transanal radiofrequency for fecal incontinence
- Transcatheter Therapy for Severe Ticuspid Insufficiency
- Transcatheter coronary infusion of supersaturated oxygen therapy in acute myocardial infarction
- Transperineal laser ablation of the prostate for benign prostatic hyperplasia
- Tympanostomy tube delivery systems
-
V
- Vaginitis Diagnostic Testing
- Vagus nerve stimulation for post-stroke upper limb rehabilitation
- Vestibular evoked myogenic potential testing
- Video head impulse testing
- 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
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X
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