Archived Medical Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
- Acute Hospital Care at Home
- Acute In-Patient Detoxification (Opioid) PA Criteria
- Acute In-Patient Detoxification (Opioid) Prior Authorization Criteria
- Applied Behavior Analysis (ABA)
- Applied Behavior Analysis for Autism Spectrum Disorder
- Applied Behavior Analysis for Autism Spectrum Disorder
- Applied Behavior Analysis Therapy for Autism Spectrum Disorder
- Applied Behavioral Analysis (ABA) Therapy
- Applied Behavioral Analysis Therapy for Autism Spectrum Disorder
B
- Breast Cancer Index (BCI) for Managing Breast Cancer Treatment
- Breast Imaging
- Breast Pumps and Lactation Services
- Breast Pumps and Lactation Services
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery Following Mastectomy
- Breast Reconstruction Surgery Following Mastectomy
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
C
- CAR-T Medications - Abecma
- CAR-T Medications - Breyanzi
- CAR-T Medications - Kymriah
- CAR-T Medications - Tecartus
- CAR-T Medications - Yescarta
- CAR-T medications – Kymriah (tisagenlecleucel)
- CAR-T medications – Tecartus (brexucabtagene autoleucel)
- CAR-T medications – Yescarta (axicabtagene ciloleucel)
- Cardiovascular Disease Risk Testing
- Children’s Behavioral Health Respite
- Children’s Behavioral Health Respite
- Children’s Behavioral Health Respite
- Clinical Trial Coverage
- Continuity of Care
- Continuous Glucose Monitoring (CGM)
- Continuous Glucose Monitoring (CGM)
- Continuous Glucose Monitoring Systems (CGMS)
- Continuous Glucose Monitoring Systems (CGMS)
- Continuous Glucose Monitors
D
E
- Electrodiagnostic Testing: Nerve Conduction and Needle Electromyography Automated Nerve Conduction Studies
- Electrodiagnostic Testing: Nerve Conduction and Needle Electromyography Automated Nerve Conduction Studies
- Electrodiagnostic Testing: Nerve Conduction and Needle Electromyography Automated Nerve Conduction Studies
- Emergency Response Systems
- Emergency Response Systems
- Epidural Steroid Injections
- Epidural Steroid Injections
- Epidural Steroid Injections
- Epidural Steroid Injections
- Epidural Steroid Injections
- Epidural Steroid Injections (Interlaminar, Transforaminal or Caudal Epidural Injections)
- Epidural Steroid Injections (Interlaminar, Transforaminal or Caudal Epidural Injections)
- Erectile Dysfunction
- Experimental or Investigational Technologies
F
- Facet Joint Interventions
- Facet Joint Interventions
- Facet Joint Interventions
- Facet Joint Interventions
- Facet Joint Interventions
- Facet Medial Branch Nerve Blocks
- Facet Medial Branch Nerve Blocks
- Facet Neurotomy
- Facet Neurotomy
- Fraction Flow Reserve from computer tomography (FFRct)
- Fraction Flow Reserve from computer tomography (FFRct)
- Fraction Flow Reserve from computer tomography (FFRct)
G
- Gender Affirming Surgery
- Gender Affirming Surgery
- Gender Affirming Surgery
- Gender Affirming Surgery
- Gender Dysphoria
- Gender Dysphoria (GD)
- Genetic Testing and Counseling
- Genetic Testing and Counseling
- Genetic Testing and Counseling
- Genetic Testing and Counseling
- Genetic Testing and Counseling
- Genetic Testing, Genetic Screening and Genetic Counseling
- Genetic Testing, Genetic Screening and Genetic Counseling
H
- Home Health Services
- Home Health Services
- Home Medication Dispenser Devices
- Home Medication Dispenser Devices
- Hyperthermic Intraperitoneal Chemotherapy
- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
- Hypoglossal Nerve Stimulation for the Treatment of OSA
- Hypoglossal Nerve Stimulation for the Treatment of OSA
I
- Impacted Cerumen Removal
- Impacted Cerumen Removal
- Implantable Pain Pump
- Implantable Pain Pump
- Implantable Pain Pump
- Implantable Pain Pump
- Implantable Pain Pump
- Implantable Pain Pumps
- Implantable Spinal Cord Stimulator
- Implantable Spinal Cord Stimulator
- Implantable Spinal Cord Stimulator
- Implantable Spinal Cord Stimulator
- Implantable Spinal Cord Stimulator
- Implantable Spinal Cord Stimulator (SCS) Devices
- Inhaled Nitric Oxide
- Inhaled Nitric Oxide
- Inhaled Nitric Oxide
- Inhaled Nitric Oxide
- Insulin Infusion Pump
- Insulin Infusion Pump
- Insulin Infusion Pump
- Insulin Infusion Pump
- Insulin Infusion Pump Therapy for Diabetes
- Insulin Infusion Pump Therapy for Diabetes
- Intraosseous Basivertebral Nerve Ablation
- Intraosseous Basivertebral Nerve Ablation
K
L
M
- Mastectomy for Gynecomastia
- Mastectomy for Gynecomastia
- Mastectomy for Gynecomastia
- Mechanical Stretching Devices
- Mechanical Stretching Devices
- Mechanical Stretching Devices
- Metabolic and Bariatric Surgery in Adolescents
- Metabolic and Bariatric Surgery in Adolescents
- Metabolic and Bariatric Surgery in Adolescents
- Metabolic and Bariatric Surgery in Adults 20 and Older
- Metabolic and Bariatric Surgery in Adults 20 and Older
- Metabolic and Bariatric Surgery in Adults 20 and Older
- Metabolic and Bariatric Surgery Revision
- Metabolic and Bariatric Surgery-Revision
- Metabolic and Bariatric Surgery: Revision
- Metabolic and Bariatric Surgery: Revision
- Minimally Invasive Gastroesophageal Reflux Disease (GERD) Treatment
- Myoelectric Lower Extremity Orthotic Technology
N
- National and Local Coverage Determinations
- Negative Pressure Wound Therapy (NPWT)
- Negative Pressure Wound Therapy (NPWT)
- Negative Pressure Wound Therapy (NPWT)
- Negative Pressure Wound Therapy (NPWT)
- Negative Pressure Wound Therapy (NPWT)
- Neonatal Discharge Criteria
- Neonatal Discharge Criteria
- Neonatal Discharge Criteria
- No Policy Determinations
- Non-Emergency Facility to Facility Transfers
- Nursing Facility – Level of Care
- Nursing Facility Level of Care
- Nursing Facility Level of Care
- Nutritional Supplement
- Nutritional Supplements
- Nutritional Supplements
- Nutritional Supplements
- Nutritional Supplements
- Nutritional Supplements
- Nutritional Supplements
- Nutritional Supplements
- Nutritional Supplements
O
P
- Pain Management Interventional Procedures
- Pediatric Speech-Language Therapy
- Penile Implants in the Treatment of Erectile Dysfunction
- Penile Implants in the Treatment of Erectile Dysfunction
- Penile Implants in Treatment of Erectile Dysfunction
- Penile Implants in Treatment of Erectile Dysfunction
- Peripheral Nerve Blocks
- Peripheral Nerve Blocks for Treatment of Pain
- Peripheral Nerve Stimulators
- Peripheral Nerve Stimulators for Treatment of Pain
- Peripheral Nerve Stimulators for Treatment of Pain
- Peroral Endoscopic Myotomy (POEM)
- Peroral Endoscopic Myotomy (POEM)
- Personal Emergency Response System
- Personal Emergency Response System
- Personal Emergency Response Systems
- Positive Airway Pressure Devices for Pulmonary Disorders
- Positive Airway Pressure Devices for Pulmonary Disorders
- Positive Airway Pressure Devices for Pulmonary Disorders
- Positive Airway Pressure Devices for Pulmonary Disorders
- Private Duty Nursing
- ProACT Adjustable Continence Therapy
- ProACT Adjustable Continence Therapy
R
S
- Sacroiliac Joint Fusion
- Sacroiliac Joint Fusion
- Sacroiliac Joint Fusion
- Sacroiliac Joint Injection
- Sacroiliac Joint Procedures
- Sacroiliac Joint Procedures
- Sacroiliac Joint Procedures
- Sacroiliac Joint Procedures
- Sacroiliac Joint Procedures
- Saphenous Vein Ablation, Adhesive Injection
- Screening and Diagnostic Mammography
- Screening and Surveillance for Colorectal Cancer
- Screening and Surveillance for Colorectal Cancer
- Serum Biomarker Panel Testing in Systemic Lupus Erythematosus and Rheumatoid Arthritis
- Serum Biomarker Panel Testing in Systemic Lupus Erythematosus and Rheumatoid Arthritis
- Serum Biomarker Panel Testing in Systemic Lupus Erythematosus and Rheumatoid Arthritis
- Skin Substitutes
- Skin Substitutes
- Special Needs Car Seats
- Speech Generating Devices
- Stab Phlebectomy
- Standing Frames
- Standing Frames
T
- Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation for Treatment of Depression
- Transcranial Magnetic Stimulation for Treatment of Depression
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Tumor Treatment Field Devices for Glioblastoma Multiforme
- Tumor Treatment Field Devices for Glioblastoma Multiforme