Medical Policies
Clinical Review Criteria
The information below should not be considered your actual policy of insurance. It should be noted that not all of the services listed in the medical policies and criteria may be covered (included) under your existing policy. For Medicare Advantage Members this criterion is utilized when there is no Centers for Medicare and Medicaid Service(CMS) National Coverage Determinations or Local Coverage Determination policies. Please reference your plan or group policy for more specifics or Contact FirstCarolinaCare customer service if you have any questions.
- Abdominoplasty/Panniculectomy
- Advance Coverage Determinations (ACDs): Appropriate Notice of Medicare Non-Coverage
- Ambulance Transport Services: Commercial and Medicare Advantage Products
- Autism Spectrum Disorders
- Autologous Chondrocyte Transplant (ACT), Implant (ACI), Osteochondral Allograft, Osteochondral Autograft (OATS-mosaicplaty)
- Balloon Ostial Dilation with Nasal/Sinus Endoscopy
- Bariatric Surgery for Severe Obesity
- Blepharoplasty and Eyelid/Brow Ptosis Repair
- Bone Growth Stimulators: Electrical and Ultrasonic
- Bone Marrow Harvesting and Storage, Human Leukocyte Antigen (HLA) Testing
- Bone Morphogenetic Protein, Recombinant Human and Other Bone Graft Substitutes and Adjuncts
- Breast Reconstruction, Revision of Reconstruction, and Implant Removal and Replacement
- Cataract Removal
- Chimeric Antigen Receptor T-Cell (CAR-T) Therapy
- Chiropractic Services
- Clinical Trials Participation Benefit
- Cochlear Implant
- Complementary and Alternative Medicine/Therapies (CAM)
- Complications Arising from Non-Covered Services
- Computerized Tomography (CT)
- Continuous Glucose Monitoring: Long-Term
- Cosmetic, Post-Accidental/Surigical Trauma, and Reconstructive Surgery
- Cranial Orthotic Devices
- Deep Brain Stimulation for Parkinson's, Essential Tremor, Dystonia, Refractory Epilepsy, Electrodes for Pre-op Mapping, and Obsessive-Complusive Disorder
- Dental Services
- Durable Medical Equipment (DME) and Medical Supplies
- Electrical Stimulation for Gastroparesis
- Electrophysiology (EP) Testing
- Endovascular Intervention, Peripheral Artery
- Enteral/Parenteral Nutritional Products: Home/Outpatient
- Experimental and/or Investigational Services
- External Counterpulsation for Angina Pectoris
- Fertility Preservation Services
- Gender Affirmation Surgery
- Genetic Testing/Molecular Diagnostics
- Gynecomastia
- Hearing Aids and Bone-Anchored Hearing Aids (BAHA)
- Home Birth
- Home Services - Intermittent Skilled and Private Duty Nursing
- Hospice Care
- Hospital Beds/Mattresses - Support Surfaces
- Hyberbaric Oxygen Therapy
- Hypoglossal Cranial Nerve Stimuation for Treatment of Obstructive Sleep Apnea
- Hysteroscopy
- Infertility Benefits
- Inpatient vs Outpatient Surgery Guidelines
- Insulin Pumps
- InterStim for Fecal Incontinence Treatment
- Laser Interstitial Thermal Therapy
- Laser Treatment of Port-Wine Stains - Hemangiomas
- Laser Treatment of Psoriasis and Other Dermatology Conditions
- Left Atrial Appendage Closure Devices, Percutaneous): Watchman, Amplatzer Cardiac Plug (Amulet). Lariat
- Left Ventriular-Assist Devices (VAD)/Total Artificial Heart/Impella, Percutaneous Assist Device
- Life Style Activities of Daily Living (ADLs), Edcational and Training Programs
- Lift Chairs
- Light Boxes
- Long Term Acute Care Hospital (LTACH)
- Lung Volume Reduction Surgery
- Magnetic Resonance Imaging (MRI)
- Medical Nerve Decompression - Carpal Tunnel Release
- Meniscal Allograft Transplantation
- Mental Health and Substance Use Treatment
- Myringotomy and Tympanoplasty
- Obstructive Sleep Apnea Diagnosis (Sleep Studies: Home/Unattended Portable & Facility) and Treatment
- Occupational (OT) and Physical (PT) Therapies
- Optune Electric Tumor Treatment Fields (ETTF) for the Treatment of Glioblastoma
- Osteotomies
- Oxygen
- Partial Breast Irradiation - MammoSite/SAVI
- Pectus Excavatum: Surgical Correction
- Plasma Exchange, Therapeutic (TPE)
- Pneumatic Compression Devices for the Treatment of Chronic Venous Insufficiency, Lymphedema, or Prevention of Deep Vein Thrombosis
- Positron Emission Tomography (PET) Scans
- Prostate Cancer Prognostic Tests Prebiopsy/Repeat Biopsy: 4K Score, ConfrimMDX, PCA3 Assay, Prostate Health Index, ExoDX Prostate, Select MDx
- Prosthetics and Customized Orthotics
- Proton Beam Therapy
- Radiofrequency Ablation (RFA) or Cryoablation, Renal
- Recurrent Pregnancy Loss
- Reduction Mammoplasty, Female
- Refractive Corneal Surgery
- Rehabiliation Services, Acute Inpatient
- Rethymic Allogeneic Thymocyte-Depleted Thymus Tissue Transplant for Treatment of Congenital Athymia
- Rhinoplasty
- Sacral Nerve Stimulation for Urinary Dysfunction: InterStim, Axonics
- Secretion Clearance Devices
- Skilled Inpatient Care
- Skin and Soft Tissue Lesions - Removal in a Facility
- Skin Substitutes and Application Criteria
- Speech Generating Devices
- Spinal Cord Stimulator & Pain Assessment
- Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (CyberKnife, Gamma Knife and Linear Accelerator)
- Temporomandibular Joint (TMJ) Services
- Tonsillectomy and Adenoidectomy
- Total Ankle Replacement - Arthroplasty
- Total Hip Replacement
- Total Knee Replacement
- Transcranial Magnetic Stimulation
- Transplantation
- Urinary Dysfunction Treatments
- Uterine Artery Embolization
- Uvulopalatopharyngoplasty (UPPP)
- Vagus Nerve Stimulation for Refactory Epilepsy and the Investigational Indications
- Vasectomy
- Ventilators- In Home Use: Noninvasive Interface (e.g., facemask) (Trilogy, Astral) and Invasive Interface (e.g., tracheostomy)
- Video Capsule Endoscopy
- Vision Prescriptions: Intraocular and Contact Lenses and Glasses
- Vision Therapy (Orthopotics)
- Wearable Cardiac Defibrillator (WCD)
- Wheelchairs