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Clinical review
For information concerning whether a specific service or benefit is covered, please refer to your Evidence of Coverage, or call Kaiser Permanente Member Services toll-free at 1-800-777-7902 (711 TTY)
The documents below are available to detail the review process and procedures:
A
- Acupuncture (PDF)
- Ambulance Transportation (PDF)
- Aquablation (PDF)
- Aquatic Therapy (PDF)
- Autism Spectrum Disorder (PDF)
B
- Bariatric Surgery (PDF)
- Benign Skin Lesion Treatment (PDF)
- Biofeedback (PDF)
- Blepharoplasty (PDF)
- Breast Implant Removal (PDF)
- Breast Prosthesis, External (PDF)
- Breast Pump (PDF)
- Breast Reduction (PDF)
C
- Capsule Endoscopy (PDF)
- Cardiac Rehabilitation (PDF)
- Cervical Traction Device (PDF)
- Chiropractic Services (PDF)
- Circumcision Revision (PDF)
- Cochlear and Auditory Brain Stem Implants (PDF)
- Cologuard (PDF)
- Compression Garment and Pneumatic Device (PDF)
- Continuous Glucose Monitor (PDF)
- Continuous Passive Motion (CPM Machine) (PDF)
- Corneal Collagen Crosslinking (PDF)
- Cranial Remodeling Bands and Helmets (PDF)
D
- Dental Services under Medical Benefit (PDF)
- Dermal Fillers (PDF)
E
- Electrical Patient Lift (PDF)
- Electrolysis for Hair Removal (PDF)
- Endobronchial Valve (PDF)
- External Insulin Pumps and Supplies (PDF)
F
- Fertility Preservation for Iatrogenic Infertility (PDF)
- Fetal Echocardiogram (PDF)
- Functional Electrical Stimulation (PDF)
G
- Gender Affirming Care D.C Jurisdiction (PDF)
- Gender Affirming Care: FEDS/MD/VA Jurisdiction (PDF)
- Genetic Testing (PDF)
H
- Habilitative Therapy (PDF)
- Hair Prosthesis (Wig) (PDF)
- High Frequency Chest Wall Oscillation Device (PDF)
- Hippotherapy (PDF)
- Home Care (PDF)
- Home Oxygen Therapy (PDF)
- Home Ultraviolet B (UBV) Phototherapy (PDF)
- Hyperbaric Oxygen (PDF)
- Hypoglossal Nerve Stimulator (PDF)
I
K
- Knee Scooter (PDF)
L
- Laser treatment/ Electrolysis for Hair Removal or Hair Reduction (PDF)
- Lymphedema & Lipedema Surgical Treatment (PDF)
M
- Mastectomy External Prosthesis (PDF)
- Matrix-Induced Autologous Chondrocyte Implantation (MACI) Procedure (PDF)
- Mechanical Stretching Device (PDF)
- Medical Neccesity for Pre Authorization, Multiple Visit (PDF)
- Medical Neccesity for Pre Authorization, Single Visit (PDF)
- miraDry System (PDF)
- MRI: External (PDF)
N
- Nutritional Support (PDF)
O
- Orthognathic Surgery (PDF)
- Orthosis, Lower Extremity (PDF)
- Orthosis, Spinal (PDF)
- Orthosis, Upper Extremity (PDF)
- Osteogenic Stimulator (PDF)
P
- Panniculectomy (PDF)
- Pectus Excavatum Surgery (PDF)
- Pediatric Feeding Therapy (PDF)
- Pelvic Floor Rehabilitation (PDF)
- Pharmacogenetic Testing for Behavioral Health Disorders (PDF)
- Phrenic Nerve Stimulator (PDF)
- Pluvicto (PDF)
- Preimplantation Genetic Testing (PGT) (PDF)
- Prostheses, Upper Extremities (PDF)
- Prosthodontic Reconstruction after Reconstructive Jaw Surgery (PDF)
- Pulsed Dye Laser (PDL) for Vascular Lesions (PDF)
- Purewick (PDF)
R
- Routine Foot Care (PDF)
S
- Sensory Integration Therapy (PDF)
- Sialendoscopy or Sialoendoscopy (PDF)
- Sipuleucal-T (Provenge) (PDF)
- SpaceOAR (PDF)
- Spinal Cord Stimulation (PDF)
T
- Transcutaneous Tibial Nerve Stimulator (TTNS) (PDF)
- Treatment of Temporomandibular Disorders (TMD) or Temporomandibular Joint Syndrome (TMJD) (PDF)
V
- Varicose Veins, Evaluation and Treatment (PDF)
- Virtual Colonoscopy: D.C/FED/VA Jurisdiction (PDF)
- Virtual Colonoscopy: MD Jurisdiction (PDF)
- Viscosupplementation (PDF)
- Vision Therapy (PDF)
- Vitiligo Treatment (PDF)
W
- Wound Supplies (PDF)
- Wound Vacuum (PDF)
Kaiser Permanente also utilizes externally developed clinical criteria. Those documents can be reviewed here.