| Behavioral Health |
MP-001 |
Transcranial Magnetic Stimulation-Repetitive (rTMS) |
February 04, 2025 |
December 04, 2024 |
December 04, 2025 |
| General Surgery |
mp-002 |
Gender Affirming Surgery |
January 22, 2025 |
January 22, 2025 |
January 22, 2026 |
| Pediatrics |
MP-003 |
Chromosomal Microarray (CMA)/Comparative Genomic Hybridization (CGH) Testing for Developmental Delay and Fetal Demise |
February 19, 2025 |
February 19, 2025 |
February 19, 2026 |
| Pulmonary |
MP-004 |
Hypoglossal Nerve Stimulator for Obstructive Sleep Apnea |
February 19, 2025 |
February 19, 2025 |
February 19, 2026 |
| Ear, Nose, and Throat (ENT) |
MP-005 |
Balloon Dilation of the Eustachian Tube |
May 20, 2024 |
March 20, 2024 |
March 20, 2025 |
| Gastroenterology |
MP-006 |
DNA Analysis of Stool for Colon Cancer Screening (Cologuard ®) |
July 17, 2024 |
July 17, 2024 |
July 17, 2025 |
| Endocrinology |
MP-007 |
Ambulatory Insulin Pumps and Closed-Loop Insulin Delivery Systems |
October 16, 2024 |
October 16, 2024 |
October 16, 2025 |
| Endocrinology |
MP-008 |
Continuous Glucose Monitor (CGM) |
October 28, 2024 |
August 28, 2024 |
August 28, 2025 |
| Radiation Therapy |
MP-009 |
Proton Beam Therapy |
August 21, 2024 |
August 21, 2024 |
August 21, 2025 |
| Cardiovascular |
mp-010 |
Enhanced External Counter Pulsation |
January 22, 2025 |
January 22, 2025 |
January 22, 2026 |
| Dermatology |
MP-011 |
Benign Skin Lesion Removal |
September 18, 2024 |
September 18, 2024 |
September 18, 2025 |
| Gastroenterology |
MP-012 |
Formulas and Other Enteral Nutrition |
July 01, 2024 |
April 24, 2024 |
April 24, 2025 |
| Allergy/Immunology |
MP-013 |
Allergy Testing |
November 25, 2024 |
September 25, 2024 |
September 25, 2025 |
| Dermatology |
MP-014 |
Treatment of Congenital Hemangiomas (Port Wine Stains) |
October 16, 2024 |
October 16, 2024 |
October 16, 2025 |
| Gastroenterology |
mp-015 |
Gastric Pacing |
September 18, 2024 |
September 18, 2024 |
September 18, 2025 |
| Obstetrics and Gynecology |
MP-016 |
Infertility Testing and Treatment |
January 22, 2025 |
January 22, 2025 |
January 22, 2026 |
| Radiation Therapy |
MP-017 |
Radioembolization/Selective Internal Radiation Therapy (SIRT) |
January 22, 2025 |
January 22, 2025 |
January 22, 2026 |
| Genetics |
MP-018 |
Cell-free DNA (cfDNA) Testing for Fetal Aneuploidy |
August 21, 2024 |
August 21, 2024 |
August 21, 2025 |
| Ophthalmology |
MP-019 |
Aqueous Shunts and Stents for Glaucoma |
January 20, 2025 |
November 20, 2024 |
November 20, 2025 |
| Genetics |
MP-020 |
Methylenetetrahydrofolate Reductase (MTHFR) Mutation Testing |
October 16, 2024 |
October 16, 2024 |
October 16, 2025 |
| Orthopedic |
MP-021 |
Vertical Expandable Prosthetic Titanium Rib for Spinal Disorders |
December 18, 2024 |
December 18, 2024 |
December 18, 2025 |
| Radiology, diagnostic |
MP-022 |
Breast Tomosynthesis |
October 16, 2024 |
October 16, 2024 |
October 16, 2025 |
| Physical Medicine |
mp-023 |
Chiropractic Care |
December 18, 2024 |
December 18, 2024 |
December 18, 2025 |
| Ophthalmology |
MP-024 |
Corneal Cross-linking |
October 16, 2024 |
October 16, 2024 |
October 16, 2025 |
| Genetics |
MP-025 |
Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases (e.g. Avise® CTD) |
February 19, 2025 |
February 19, 2025 |
February 19, 2026 |
| Laboratory/Pathology |
mp-026 |
Drug Levels and Antibody Testing for Infliximab, Adalimumab, Vedolizumab and Ustekinumab |
May 15, 2024 |
May 15, 2024 |
May 15, 2025 |
| Endocrinology |
MP-027 |
Vectra DA Blood Test for Rheumatoid Arthritis |
November 20, 2024 |
November 20, 2024 |
November 20, 2025 |
| Physical Medicine |
mp-028 |
Infrared Therapy |
September 18, 2024 |
September 18, 2024 |
September 18, 2025 |
| Ear, Nose, and Throat (ENT) |
MP-029 |
Vestibular Evoked Myogenic Potential (VEMP) Testing |
July 03, 2024 |
May 03, 2024 |
May 03, 2025 |
| Behavioral Health |
MP-030 |
Pharmacogenomic Testing for Behavioral Health Disorders |
October 16, 2024 |
October 16, 2024 |
October 16, 2025 |
| Pulmonary |
MP-031 |
High Frequency Chest Wall Compression (e.g. The Vest Airway Clearance System) |
January 22, 2025 |
January 22, 2025 |
January 22, 2026 |
| Ear, Nose, and Throat (ENT) |
MP-032 |
Transtympanic Micropressure Treatment for Ménière’s Disease |
November 20, 2024 |
November 20, 2024 |
November 20, 2025 |
| Genetics |
MP-033 |
Genetic Testing for Breast and/or Ovarian Cancer Susceptibility (BRCA1/BRCA2) |
January 22, 2025 |
January 22, 2025 |
January 22, 2026 |
| Cardiovascular |
MP-035 |
Implantable Hemodynamic Monitor for Managing Patients with Heart Failure (e.g. CardioMEMS) |
December 18, 2024 |
December 18, 2024 |
December 18, 2025 |
| Neurology/Neurosurgery |
MP-036 |
Transcutaneous (Non-implantable) Vagus Nerve Stimulation (e.g. gammaCore-S ®) |
May 15, 2024 |
May 15, 2024 |
May 15, 2025 |
| Gastroenterology |
MP-037 |
Chromoendoscopy as an Adjunct to Colonoscopy |
March 19, 2025 |
March 19, 2025 |
March 19, 2026 |
| Hematology/Oncology |
MP-038 |
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) |
March 19, 2025 |
March 19, 2025 |
March 19, 2026 |
| Radiology, diagnostic |
MP-039 |
MRI Guided Focused Ultrasound (MRgFUS) |
May 15, 2024 |
May 15, 2024 |
May 15, 2025 |
| Radiology, diagnostic |
MP-040 |
Low-Dose Computed Tomography for Lung Cancer Screening |
February 19, 2025 |
February 19, 2025 |
February 19, 2026 |
| Radiology, diagnostic |
MP-041 |
Bone Mineral Density Studies |
October 28, 2024 |
August 28, 2024 |
August 28, 2025 |
| Hematology/Oncology |
MP-042 |
Electric Tumor Treatment Field Therapy for the Treatment of Glioblastoma Multiforme |
May 15, 2024 |
May 15, 2024 |
May 15, 2025 |
| Gastroenterology |
MP-043 |
Fecal Elastase (FE-1) Testing |
November 25, 2024 |
September 25, 2024 |
September 25, 2025 |
| Hematology/Oncology |
MP-044 |
Flow Cytometry |
July 17, 2024 |
July 17, 2024 |
July 17, 2025 |
| Genetics |
mp-045 |
General Policy for Genetic Testing |
May 15, 2024 |
May 15, 2024 |
May 15, 2025 |
| Genetics |
MP-046 |
Carrier Screening for Genetic Diseases |
January 22, 2025 |
January 22, 2025 |
January 22, 2026 |
| Ophthalmology |
MP-047 |
Flicker Fusion |
April 16, 2025 |
April 16, 2025 |
April 16, 2026 |
| Dermatology |
MP-048 |
Phototherapy, Photochemotherapy or PUVA, and Excimer Laser Therapy for Dermatologic Conditions |
January 22, 2025 |
January 22, 2025 |
January 22, 2026 |
| Orthopedic |
MP-049 |
Sacroiliac Joint (SI) Joint Fusion |
October 28, 2024 |
August 28, 2024 |
August 28, 2025 |
| Ophthalmology |
MP-051 |
Electroretinography |
November 20, 2024 |
November 20, 2024 |
November 20, 2025 |
| General Surgery |
MP-052 |
Bariatric Surgery |
August 26, 2024 |
June 26, 2024 |
June 26, 2025 |
| Physical Medicine |
MP-053 |
Vertebral Axial Decompression |
December 18, 2024 |
December 18, 2024 |
December 18, 2025 |
| Laboratory/Pathology |
MP-055 |
Homocysteine Level Testing |
July 17, 2024 |
July 17, 2024 |
July 17, 2025 |
| Laboratory/Pathology |
MP-056 |
Vitamin D Testing |
May 15, 2024 |
May 15, 2024 |
May 15, 2025 |
| Dermatology, Genetics |
MP-057 |
Genetic Testing for Melanoma |
August 21, 2024 |
August 21, 2024 |
August 21, 2025 |
| Neurology/Neurosurgery |
MP-058 |
Intraoperative Neuromonitoring (IONM) |
August 21, 2024 |
August 21, 2024 |
August 21, 2025 |
| Physical Medicine |
MP-059 |
Dry Needling |
July 17, 2024 |
July 17, 2024 |
July 17, 2025 |
| Dermatology |
MP-060 |
CO2 (Carbon Dioxide) Fractional Ablative Laser Treatment for Burn Scars |
August 21, 2024 |
August 21, 2024 |
August 21, 2025 |
| Neurology/Neurosurgery |
MP-061 |
Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation |
December 16, 2024 |
October 16, 2024 |
October 16, 2025 |
| Gastroenterology |
MP-062 |
Fecal Microbiota Transplant |
July 17, 2024 |
July 17, 2024 |
July 17, 2025 |
| Cardiovascular |
MP-063 |
Radiofrequency Ablation of the Renal Sympathetic Nerve |
October 28, 2024 |
August 28, 2024 |
August 28, 2025 |
| Allergy/Immunology |
MP-064 |
Sublingual Immunotherapy (SLIT) |
March 19, 2025 |
March 19, 2025 |
March 19, 2026 |
| Behavioral Health |
mp-065 |
Eye Movement Desensitization and Reprocessing (EMDR) Therapy |
August 26, 2024 |
June 26, 2024 |
June 26, 2025 |
| Cardiovascular |
MP-066 |
Myocardial Strain Imaging |
March 19, 2025 |
March 19, 2025 |
March 19, 2026 |
| Durable Medical Equipment (DME) |
mp-067 |
Speech Generating Devices |
July 17, 2024 |
July 17, 2024 |
July 17, 2025 |
| Orthopedic |
MP-068 |
Intraosseous Basivertebral Nerve Ablation Procedure (Intracept) |
December 18, 2024 |
December 18, 2024 |
December 18, 2025 |
| Laboratory/Pathology |
MP-069 |
Serologic Testing for Liver Fibrosis |
February 19, 2025 |
February 19, 2025 |
February 19, 2026 |
| Pulmonary |
MP-070 |
Sleep Studies |
March 22, 2025 |
January 22, 2025 |
January 22, 2026 |
| General Surgery |
mp-071 |
Therapeutic Nerve Blocks for Post-Operative Pain Management |
January 20, 2025 |
November 20, 2024 |
November 20, 2025 |
| Genitourinary |
mp-073 |
Prostatic Urethral Lift (UroLift®) for Benign Prostatic Hypertrophy |
December 18, 2024 |
December 18, 2024 |
December 18, 2025 |
| Orthopedic |
MP-074 |
Platelet-Rich Plasma (PRP) for Orthopedic Indications |
December 18, 2024 |
December 18, 2024 |
December 18, 2025 |
| Orthopedic |
MP-075 |
Autologous Chondrocyte Implantation |
March 19, 2025 |
March 19, 2025 |
March 19, 2026 |
| Genitourinary |
MP-076 |
Sacral Nerve Stimulation for Pelvic Floor Dysfunction |
March 19, 2025 |
March 19, 2025 |
March 19, 2026 |
| Neurology/Neurosurgery |
MP-077 |
Transcutaneous or Peripheral Magnetic Stimulation (TCMS/PMS) |
October 28, 2024 |
August 28, 2024 |
August 28, 2025 |
| Orthopedic |
mp-078 |
Dynamic Splint Devices |
September 18, 2024 |
September 18, 2024 |
September 18, 2025 |
| Orthopedic |
mp-079 |
Arthroereisis and Subtalar Implants |
September 18, 2024 |
September 18, 2024 |
September 18, 2025 |
| Behavioral Health |
mp-080 |
Transcranial Magnetic Stimulation-Single Pulse (e.g. eNeura SAVI Dual™) |
November 20, 2024 |
November 20, 2024 |
November 20, 2025 |
| Behavioral Health |
MP-081 |
Cognitive Rehabilitation Therapy |
October 28, 2024 |
August 28, 2024 |
August 28, 2025 |