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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)
Please tell us your location so we can take you to information customized for that area.
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)
- Compression Garment (PDF)
- Cologuard (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
- Feeding (PDF)
- Fertility Preservation for Iatrogenic Infertility (PDF)
- Fetal Echocardiogram (PDF)
- Functional Electrical Stimulation (PDF)
G
- Gender Affirming Surgical Procedures (PDF)
- Genetic Testing (PDF)
H
- Habilitative Therapy (PDF)
- High Frequency Chest Wall Oscillation Device (PDF)
- Hippotherapy (PDF)
- Home Care (PDF)
- Home Oxygen Therapy (PDF)
- Home Ultraviolet B (UBV) Phototherapy (PDF)
- Hospital bed home use (PDF)
- Hyperbaric Oxygen (PDF)
- Hypoglossal Nerve Stimulator (PDF)
I
K
- Knee Scooter (PDF)
L
- Laparoscopic Magnetic Sphincter Augmentation (PDF)
- Laser treatment/ Electrolysis for Hair Removal or Hair Reduction (PDF)
- Laser treatment (PDL) for Vascular Malformations and Port Wine Stains (PDF)
- Lymphedema & Lipedema Surgical Treatment (PDF)
M
- Mastectomy External Prosthesis (PDF)
- Matrix-Induced Autologous Chondrocyte Implantation (MACI) Procedure (PDF)
- Mechanical Stretching Device (PDF)
- Medical Necessity for Pre Authorization, Multiple Visit (PDF)
- Medical Necessity for Pre Authorization, Single Visit (PDF)
- miraDry System (PDF)
- MRI: External (PDF)
N
- Negative Pressure Wound Therapy (PD)
- Nidra TOMAC Therapy (PDF)
- 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)
- PET-CT Ocnology (PDF)
- PET-CR Non-Ocnology (PDF)
- Pelvic Floor Rehabilitation (PDF)
- Phrenic Nerve Stimulator (PDF)
- Pluvicto (PDF)
- Preimplantation Genetic Testing (PGT) (PDF)
- Prostheses, Eye (PDF)
- Prosthesis, Lower Extremity (PDF)
- Prosthesis, Upper Extremity (PDF)
- Prosthodontic Reconstruction after Reconstructive Jaw Surgery (PDF)
- Pulsed Dye Laser (PDL) for Vascular Lesions (PDF)
- Purewick (PDF)
R
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)
- Visco Supplementation (PDF)
- Vision Therapy (PDF)
- Vitiligo Treatment (PDF)
W
- Wound Supplies (PDF)
- Wound Vacuum (PDF)
Kaiser Permanente also utilizes externally developed clinical criteria. Review the external criteria documents.