Medical Policies

Administrative

Reimbursement Policies

Pharmacy

Dental

New Policies

Updated Policies

Upcoming Policies
Policy Name Effective Date Revision Date Next Review Date
A
MP-007 Ambulatory Insulin Pumps and Closed-Loop Insulin Delivery Systems September 16, 2020 September 16, 2020 September 16, 2021
B
MP-005 Balloon Dilation of the Eustachian Tube August 26, 2020 August 26, 2020 August 26, 2021
MP-052 Bariatric Surgery December 31, 2019 December 18, 2019 December 18, 2020
MP-022 Breast Tomosynthesis September 17, 2020 September 16, 2020 September 16, 2021
MP-011 Benign Skin Lesion Removal September 16, 2020 September 16, 2020 September 16, 2021
C
MP-046 Carrier Screening for Genetic Diseases December 19, 2020 October 09, 2020 October 09, 2021
MP-060 CO2 (Carbon Dioxide) Fractional Ablative Laser Treatment for Burn Scars October 26, 2020 August 26, 2020 August 26, 2021
MP-018 Cell-free DNA (cfDNA) Testing for Fetal Aneuploidy December 26, 2020 October 26, 2020 October 26, 2021
MP-037 Chromoendoscopy as an Adjunct to Colonoscopy May 20, 2020 May 20, 2020 May 20, 2021
MP-038 Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) August 26, 2020 August 26, 2020 August 26, 2021
MP-003 Chromosomal Microarray (CMA)/Comparative Genomic Hybridization (CGH) Testing for Developmental Delay and Fetal Demise November 18, 2020 November 18, 2020 November 18, 2021
MP-014 Treatment of Congenital Hemangiomas (Port Wine Stains) September 16, 2020 September 16, 2020 September 16, 2021
MP-008 Continuous Glucose Monitor (CGM) June 12, 2020 June 12, 2020 June 12, 2021
MP-024 Corneal Cross-linking November 18, 2020 November 18, 2020 November 18, 2021
D
MP-006 DNA Analysis of Stool for Colon Cancer Screening (Cologuard ®) October 03, 2020 August 03, 2020 August 03, 2021
MP-059 Dry Needling September 22, 2020 July 22, 2020 July 22, 2021
E
MP-042 Electric Tumor Treatment Field Therapy for the Treatment of Glioblastoma Multiforme May 20, 2020 May 20, 2020 May 20, 2021
MP-051 Electroretinography November 18, 2020 November 18, 2020 November 18, 2021
F
MP-062 Fecal Microbiota Transplant December 13, 2020 September 30, 2020 September 30, 2021
MP-044 Flow Cytometry September 22, 2020 July 22, 2020 July 22, 2021
MP-012 Formulas and Other Enteral Nutrition September 16, 2020 September 16, 2020 September 16, 2021
G
MP-002 Gender Reassignment Surgery March 6, 2020 January 6, 2020 January 6, 2021
MP-033 Genetic Testing for Breast and/or Ovarian Cancer Susceptibility (BRCA1/BRCA2) January 20, 2021 January 20, 2021 January 20, 2022
MP-057 Genetic Testing for Melanoma October 26, 2020 August 26, 2020 August 26, 2021
H
MP-055 Homocysteine Level Testing October 01, 2020 June 24, 2020 June 24, 2021
MP-004 Hypoglossal Nerve Stimulator for Obstructive Sleep Apnea July 1, 2020 May 1, 2020 May 1, 2021
I
MP-035 Implantable Hemodynamic Monitor for Managing Patients with Heart Failure (e.g. CardioMEMS) December 16, 2020 December 16, 2020 December 16, 2021
MP-016 Infertility Testing and Treatment December 16, 2020 December 16, 2020 December 16, 2021
MP-058 Intraoperative Neuromonitoring (IONM) September 22, 2020 July 22, 2020 July 22, 2021
MP-019 Implanted Intraocular Devices for the Treatment of Glaucoma August 12, 2020 June 12, 2020 June 12, 2021
M
MP-020 Methylenetetrahydrofolate Reductase (MTHFR) Mutation Testing November 18, 2020 November 18, 2020 November 18, 2021
MP-039 MRI Guided Focused Ultrasound (MRgFUS) June 17, 2020 June 17, 2020 June 17, 2021
P
MP-061 Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation September 22, 2020 July 22, 2020 July 22, 2021
MP-030 Pharmacogenomic Testing for Behavioral Health Disorders October 21, 2020 October 21, 2020 October 21, 2021
MP-048 Phototherapy, Photochemotherapy or PUVA, and Excimer Laser Therapy for Dermatologic Conditions October 21, 2020 October 21, 2020 October 21, 2021
MP-009 Proton Beam Therapy November 02, 2020 August 26, 2020 August 26, 2021
R
MP-017 Radioembolization/Selective Internal Radiation Therapy (SIRT) December 16, 2020 December 16, 2020 December 16, 2021
T
Admin-017 Temporary COVID-19 Telemedicine Policy September 03, 2020 September 03, 2020 February 26, 2021
MP-001 Transcranial Magnetic Stimulation (TMS) August 26, 2020 August 26, 2020 August 26, 2021
MP-036 Transcutaneous (Non-implantable) Vagus Nerve Stimulation (e.g. gammaCore-S®) May 20, 2020 May 20, 2020 May 20, 2021
MP-032 Transtympanic Micropressure Treatment for Ménière’s Disease November 18, 2020 November 18, 2020 November 18, 2021
V
MP-027 Vectra DA Blood Test for Rheumatoid Arthritis November 18, 2020 November 18, 2020 November 18, 2021
MP-053 Vertebral Axial Decompression Decemeber 16, 2020 Decemeber 16, 2020 Decemeber 16, 2021
MP-029 Vestibular Evoked Myogenic Potential (VEMP) Testing November 18, 2020 November 18, 2020 November 18, 2021
MP-056 Vitamin D Testing October 01, 2020 June 24, 2020 June 24, 2021