Skip to main content
Medical Coverage Policy

Medical Policies

SEARCH POLICIES

 

POLICIES BY CATEGORY

Behavioral Health MP-001 Transcranial Magnetic Stimulation-Repetitive (rTMS) July 24, 2023 May 24, 2023 July 24, 2024
General Surgery mp-002 Gender Affirming Surgery March 25, 2023 January 25, 2023 January 25, 2024
Pediatrics MP-003 Chromosomal Microarray (CMA)/Comparative Genomic Hybridization (CGH) Testing for Developmental Delay and Fetal Demise January 18, 2023 January 18, 2023 January 18, 2024
Pulmonary MP-004 Hypoglossal Nerve Stimulator for Obstructive Sleep Apnea February 15, 2023 February 15, 2023 February 15, 2024
Ear, Nose, and Throat (ENT) MP-005 Balloon Dilation of the Eustachian Tube May 06, 2023 March 06, 2023 March 06, 2024
Gastroenterology MP-006 DNA Analysis of Stool for Colon Cancer Screening (Cologuard ®) June 21, 2023 June 21, 2023 June 21, 2024
Endocrinology MP-007 Ambulatory Insulin Pumps and Closed-Loop Insulin Delivery Systems October 24, 2022 October 24, 2022 October 24, 2023
Endocrinology MP-008 Continuous Glucose Monitor (CGM) September 28, 2023 July 28, 2023 July 28, 2024
Radiation Therapy MP-009 Proton Beam Therapy August 16, 2023 August 16, 2023 August 16, 2024
Dermatology MP-011 Benign Skin Lesion Removal October 25, 2023 October 25, 2023 October 25, 2024
Gastroenterology MP-012 Formulas and Other Enteral Nutrition November 15, 2023 November 15, 2023 November 15, 2024
Dermatology MP-014 Treatment of Congenital Hemangiomas (Port Wine Stains) October 25, 2023 October 25, 2023 October 25, 2024
Obstetrics and Gynecology MP-016 Infertility Testing and Treatment March 25, 2023 January 25, 2023 January 25, 2024
Radiation Therapy MP-017 Radioembolization/Selective Internal Radiation Therapy (SIRT) December 21, 2022 December 21, 2022 December 21, 2023
Genetics MP-018 Cell-free DNA (cfDNA) Testing for Fetal Aneuploidy August 16, 2023 August 16, 2023 August 16, 2024
Ophthalmology MP-019 Aqueous Shunts and Stents for Glaucoma June 21, 2023 June 21, 2023 June 21, 2024
Genetics MP-020 Methylenetetrahydrofolate Reductase (MTHFR) Mutation Testing October 25, 2023 October 25, 2023 October 25, 2024
Orthopedic MP-021 Vertical Expandable Prosthetic Titanium Rib for Spinal Disorders March 02, 2023 December 30, 2022 December 30, 2023
Radiology, diagnostic MP-022 Breast Tomosynthesis October 25, 2023 October 25, 2023 October 25, 2024
Ophthalmology MP-024 Corneal Cross-linking October 25, 2023 October 25, 2023 October 25, 2024
Laboratory/Pathology mp-026 Drug Levels and Antibody Testing for Infliximab, Adalimumab, Vedolizumab and Ustekinumab June 21, 2023 June 21, 2023 June 21, 2024
Endocrinology MP-027 Vectra DA Blood Test for Rheumatoid Arthritis November 15, 2023 November 15, 2023 November 15, 2024
Ear, Nose, and Throat (ENT) MP-029 Vestibular Evoked Myogenic Potential (VEMP) Testing November 16, 2022 November 16, 2022 November 16, 2023
Behavioral Health MP-030 Pharmacogenomic Testing for Behavioral Health Disorders October 25, 2023 October 25, 2023 October 25, 2024
Pulmonary MP-031 High Frequency Chest Wall Compression (e.g. The Vest Airway Clearance System) March 25, 2023 January 25, 2023 January 25, 2024
Ear, Nose, and Throat (ENT) MP-032 Transtympanic Micropressure Treatment for Ménière’s Disease November 15, 2023 November 15, 2023 November 15, 2024
Genetics MP-033 Genetic Testing for Breast and/or Ovarian Cancer Susceptibility (BRCA1/BRCA2) January 18, 2023 January 18, 2023 January 18, 2024
Cardiovascular MP-035 Implantable Hemodynamic Monitor for Managing Patients with Heart Failure (e.g. CardioMEMS) December 21, 2022 December 21, 2022 December 21, 2023
Neurology/Neurosurgery MP-036 Transcutaneous (Non-implantable) Vagus Nerve Stimulation (e.g. gammaCore-S ®) June 21, 2023 June 21, 2023 June 21, 2024
Gastroenterology MP-037 Chromoendoscopy as an Adjunct to Colonoscopy March 15, 2023 March 15, 2023 March 15, 2024
Hematology/Oncology MP-038 Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) March 15, 2023 March 15, 2023 March 15, 2024
Radiology, diagnostic MP-039 MRI Guided Focused Ultrasound (MRgFUS) June 21, 2023 June 21, 2023 June 21, 2024
Radiology, diagnostic MP-040 Low-Dose Computed Tomography for Lung Cancer Screening February 15, 2023 February 15, 2023 February 15, 2024
Hematology/Oncology MP-042 Electric Tumor Treatment Field Therapy for the Treatment of Glioblastoma Multiforme June 21, 2023 June 21, 2023 June 21, 2024
Hematology/Oncology MP-044 Flow Cytometry June 21, 2023 June 21, 2023 June 21, 2024
Genetics mp-045 General Policy for Genetic Testing June 21, 2023 June 21, 2023 June 21, 2024
Genetics MP-046 Carrier Screening for Genetic Diseases January 18, 2023 January 18, 2023 January 18, 2024
Dermatology MP-048 Phototherapy, Photochemotherapy or PUVA, and Excimer Laser Therapy for Dermatologic Conditions January 18, 2023 January 18, 2023 January 18, 2024
Ophthalmology MP-051 Electroretinography November 15, 2023 November 15, 2023 November 15, 2024
General Surgery MP-052 Bariatric Surgery June 21, 2023 June 21, 2023 June 21, 2024
Physical Medicine MP-053 Vertebral Axial Decompression December 21, 2022 December 21, 2022 December 21, 2022
Laboratory/Pathology MP-055 Homocysteine Level Testing July 19, 2023 July 19, 2023 July 19, 2024
Laboratory/Pathology MP-056 Vitamin D Testing August 21, 2023 June 21, 2023 June 21, 2024
Dermatology, Genetics MP-057 Genetic Testing for Melanoma August 21, 2023 August 16, 2023 August 16, 2024
Neurology/Neurosurgery MP-058 Intraoperative Neuromonitoring (IONM) October 01, 2023 July 31, 2023 July 31, 2024
Physical Medicine MP-059 Dry Needling July 19, 2023 July 19, 2023 July 19, 2024
Dermatology MP-060 CO2 (Carbon Dioxide) Fractional Ablative Laser Treatment for Burn Scars August 16, 2023 August 16, 2023 August 16, 2024
Neurology/Neurosurgery MP-061 Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation July 19, 2023 July 19, 2023 July 19, 2024
Gastroenterology MP-062 Fecal Microbiota Transplant January 01, 2023 January 01, 2023 January 01, 2024
Allergy/Immunology MP-064 Sublingual Immunotherapy (SLIT) March 15, 2023 March 15, 2023 March 15, 2024
Behavioral Health mp-065 Eye Movement Desensitization and Reprocessing (EMDR) Therapy March 15, 2023 March 15, 2023 March 15, 2024
Cardiovascular MP-066 Myocardial Strain Imaging March 15, 2023 March 15, 2023 March 15, 2024
Durable Medical Equipment (DME) mp-067 Speech Generating Devices June 21, 2023 June 21, 2023 June 21, 2024
Orthopedic MP-068 Intraosseous Basivertebral Nerve Ablation Procedure (Intracept) June 21, 2023 June 21, 2023 June 21, 2024
Laboratory/Pathology MP-069 Serologic Testing for Liver Fibrosis February 15, 2023 February 15, 2023 February 15, 2024
General Surgery mp-071 Therapeutic Nerve Blocks for Post-Operative Pain Management November 15, 2023 November 15, 2023 November 15, 2024
Genitourinary mp-073 Prostatic Urethral Lift (UroLift®) for Benign Prostatic Hypertrophy December 21, 2022 December 21, 2022 December 21, 2023
Orthopedic MP-074 Platelet-Rich Plasma (PRP) for Orthopedic Indications March 25, 2023 January 25, 2023 January 25, 2024
Orthopedic MP-075 Autologous Chondrocyte Implantation May 29, 2023 March 29, 2023 March 29, 2024
Genitourinary MP-076 Sacral Nerve Stimulation for Pelvic Floor Dysfunction May 29, 2023 March 29, 2023 March 29, 2024