Coverage Decisions

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This page provides a list of special treatment coverage decisions made by the Office of the Medical Director. Evidence to support these medical coverage decisions can be accessed on the Technology Assessment page.

Covered by workers comp?
For more information, click on the link in this column or call the toll-free Provider Hotline at 1-800-848-0811.	Yes			No
	With proper documentation	Only with pre-authorization	On a case-by-case basis
Acupuncture				X
AquaMED (or dry hydrotherapy)	X
Artificial disc replacement				X
Autologous blood injections				X
Autologous chondrocyte implantation (ACI)		X
Bloodborne pathogens	X
Bone cements for use during kyphoplasty and vertebroplasty				X
Bone growth stimulators		X
Bone morphogenic proteins (BMP) for long bone nonunions and spinal fusions		X
Botulinum toxin		X
Brevio® Nerve Conduction Testing System				X
Cervical traction devices	X
Ctrac™ for CTS wrist splint				X
Discography		X
Dry needling		X
Duragesic			X
Electrical Stimulation for Chronic Wounds		X
Electrodiagnostic Sensory Nerve Conduction Threshold (sNCT)				X
Electrodiagnostic Testing	X
Epidural adhesiolysis		X
ERMI Flexionater and Extensionater				X
Extracorporeal Shockwave Therapy (ESWT)				X
Fibromyalgia				X
Futures Unlimited	X
	Yes			No
	With proper documentation	Only with pre-authorization	On a case-by-case basis
Hyaluronic acid		X
IDET (Intradiscal heating)				X
Interferential therapy units	X
Low level laser therapy				X
MedX lumbar extension machine	X
Meniscal allograft transplantation		X
Microprocessor-controlled prosthetic knees				X
NC-stat® Nerve Conduction System-NeuroMetrix®				X
Neuromuscular electrical stimulators (NMES)	X
Otto Bock Vacuum Assisted Socket System				X
Percutaneous Discectomy for Disc Herniation				X
Percutaneous Neuromodulation Therapy for low back pain				X
Posterior Lumbar Interbody Fusion (PLIF)		X
Powered Traction Devices for Intervertebral Decompression	X
Smoking cessation		X
Standing, Weight-bearing, Positional & Upright™ MRI				X
Transcutaneous Electrical Nerve Stimulator (TENS)	X
Thermal shrinkage for instability				X
Tinnitus Retraining Therapy				X
UniSpacer				X
Wound VAC			X
X-STOP® interspinous process device				X