Policy Name Effective Date Revision Date Next Review Date
A
MP-007 Ambulatory Insulin Pumps and Closed-Loop Insulin Delivery Systems September 15, 2021 September 15, 2021 September 15, 2022
B
MP-005 Balloon Dilation of the Eustachian Tube August 18, 2021 August 18, 2021 August 18, 2022
MP-052 Bariatric Surgery May 19, 2021 May 19, 2021 May 19, 2022
MP-022 Breast Tomosynthesis September 15, 2021 September 15, 2021 September 15, 2022
MP-011 Benign Skin Lesion Removal September 15, 2021 September 15, 2021 September 15, 2022
C
MP-046 Carrier Screening for Genetic Diseases March 27, 2021 January 27, 2021 January 27, 2022
MP-060 CO2 (Carbon Dioxide) Fractional Ablative Laser Treatment for Burn Scars August 18, 2021 August 18, 2021 August 18, 2022
MP-018 Cell-free DNA (cfDNA) Testing for Fetal Aneuploidy August 18, 2021 August 18, 2021 August 18, 2022
MP-037 Chromoendoscopy as an Adjunct to Colonoscopy April 21, 2021 April 21, 2021 April 21, 2022
MP-038 Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) April 10, 2021 February 10, 2021 February 10, 2022
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 15, 2021 September 15, 2021 September 15, 2022
MP-008 Continuous Glucose Monitor (CGM) September 28, 2021 July 28, 2021 July 28, 2022
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 ®) July 26, 2021 May 26, 2021 May 26, 2022
mp-026 Drug Levels and Antibody Testing for Infliximab, Adalimumab, Vedolizumab and Ustekinumab September 20, 2021 July 15, 2021 July 15, 2022
MP-059 Dry Needling July 21, 2021 July 21, 2021 July 21, 2022
E
MP-042 Electric Tumor Treatment Field Therapy for the Treatment of Glioblastoma Multiforme April 21, 2021 April 21, 2021 April 21, 2022
MP-051 Electroretinography November 18, 2020 November 18, 2020 November 18, 2021
mp-065 Eye Movement Desensitization and Reprocessing (EMDR) Therapy May 11, 2021 March 11, 2021 March 11, 2022
F
MP-062 Fecal Microbiota Transplant September 15, 2021 September 15, 2021 September 15, 2022
MP-044 Flow Cytometry July 21, 2021 July 21, 2021 July 21, 2022
MP-012 Formulas and Other Enteral Nutrition September 15, 2021 September 15, 2021 September 15, 2022
G
MP-002 Gender Reassignment Surgery August 4, 2021 May 7, 2021 May 7, 2022
mp-045 General Policy for Genetic Testing August 23, 2021 June 23, 2021 June 23, 2022
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 August 18, 2021 August 18, 2021 August 18, 2022
H
MP-055 Homocysteine Level Testing September 26, 2021 July 26, 2021 July 26, 2022
MP-004 Hypoglossal Nerve Stimulator for Obstructive Sleep Apnea April 10, 2021 February 10, 2021 February 10, 2022
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) July 21, 2021 July 21, 2021 July 21, 2022
MP-068 Intraosseous Basivertebral Nerve Ablation Procedure (Intracept) August 23, 2021 June 23, 2021 June 23, 2022
MP-019 Invasive Procedures for the Treatment of Glaucoma July 01, 2021 June 16, 2021 June 16, 2022
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 16, 2021 June 16, 2021 June 16, 2022
MP-066 Myocardial Strain Imaging June 29, 2021 April 28, 2021 April 28, 2022
P
MP-061 Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation July 21, 2021 July 21, 2021 July 21, 2022
MP-030 Pharmacogenomic Testing for Behavioral Health Disorders September 20, 2021 September 20, 2021 September 20, 2022
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 August 18, 2021 August 18, 2021 August 18, 2022
R
MP-017 Radioembolization/Selective Internal Radiation Therapy (SIRT) December 16, 2020 December 16, 2020 December 16, 2021
S
mp-067 Speech Generating Devices August 14, 2021 June 07, 2021 June 07, 2022
MP-064 Sublingual Immunotherapy (SLIT) April 10, 2021 February 10, 2021 February 10, 2022
T
MP-001 Transcranial Magnetic Stimulation (TMS) August 18, 2021 August 18, 2021 August 18, 2022
MP-036 Transcutaneous (Non-implantable) Vagus Nerve Stimulation (e.g. gammaCore-S®) April 21, 2021 April 21, 2021 April 21, 2022
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 June 16, 2021 June 16, 2021 June 16, 2022