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 January 19, 2022 January 19, 2022 January 19, 2023
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 March 16, 2022 March 16, 2022 March 16, 2023
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-038 Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) February 16, 2022 February 16, 2022 February 16, 2023
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 December 27, 2021 November 27, 2021 November 27, 2022
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 March 23, 2022 March 23, 2022 March 23, 2023
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 20, 2022 April 20, 2022 April 20, 2023
MP-051 Electroretinography November 17, 2021 November 17, 2021 November 17, 2022
mp-065 Eye Movement Desensitization and Reprocessing (EMDR) Therapy March 16, 2022 March 16, 2022 March 16, 2023
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 Affirming Surgery October 23, 2021 August 23, 2021 August 23, 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 19, 2022 January 19, 2022 January 19, 2023
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 February 16, 2022 February 16, 2022 February 16, 2023
I
MP-035 Implantable Hemodynamic Monitor for Managing Patients with Heart Failure (e.g. CardioMEMS) December 15, 2021 December 15, 2021 December 15, 2022
MP-016 Infertility Testing and Treatment January 19, 2022 January 19, 2022 January 19, 2023
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 October 27, 2021 October 27, 2021 October 27, 2022
MP-039 MRI Guided Focused Ultrasound (MRgFUS) June 16, 2021 June 16, 2021 June 16, 2022
MP-066 Myocardial Strain Imaging March 16, 2022 March 16, 2022 March 16, 2023
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-073 Prostatic Urethral Lift (UroLift®) for Benign Prostatic Hypertrophy January 15, 2022 November 15, 2021 November 15, 2022
MP-009 Proton Beam Therapy August 18, 2021 August 18, 2021 August 18, 2022
R
MP-017 Radioembolization/Selective Internal Radiation Therapy (SIRT) December 15, 2021 December 15, 2021 December 15, 2022
S
MP-069 Serologic Testing for Liver Fibrosis April 23, 2022 February 23, 2022 February 23, 2023
mp-067 Speech Generating Devices August 14, 2021 June 07, 2021 June 07, 2022
MP-064 Sublingual Immunotherapy (SLIT) February 16, 2022 February 16, 2022 February 16, 2023
T
mp-071 Therapeutic Nerve Blocks for Post-Operative Pain Management August 24, 2021 October 24, 2021 August 24, 2022
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 20, 2022 April 20, 2022 April 20, 2023
MP-032 Transtympanic Micropressure Treatment for Ménière’s Disease November 17, 2021 November 17, 2021 November 17, 2022
V
MP-027 Vectra DA Blood Test for Rheumatoid Arthritis November 17, 2021 November 17, 2021 November 17, 2022
MP-053 Vertebral Axial Decompression December 15, 2021 December 15, 2021 December 15, 2022
MP-029 Vestibular Evoked Myogenic Potential (VEMP) Testing November 17, 2021 November 17, 2021 November 17, 2022
MP-056 Vitamin D Testing June 16, 2021 June 16, 2021 June 16, 2022