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Medical Coverage Policies

Last Revised

Next Review Date

Acupuncture 01/25/2018 01/25/2019
ADHD Testing 10/17/2017 01/01/2018
Adoptive Immunotherapy 04/03/2018 04/03/2019
Affordable Care Act-Preventive Care 09/04/2018 09/04/2019
Alternating Electrical Fields Therapy 11/14/2017 11/14/2018
Apolipoprotein E Genotype or Phenotype 06/19/2018 06/19/2019
Assistant Surgeon Policy 06/05/2018 06/05/2019
Autism Spectrum Disorders 01/30/2018 01/30/2019
Biochemical Markers of Alzheimer’s Disease 05/29/2018 05/29/2019
Biologicals for Wound Care and Procedures 05/01/2018 05/01/2019
Bone Turnover Markers 05/29/2018 05/29/2019
Botilinum Toxin Injection for Chemodenervation 11/07/2017 11/07/2018
Bone Graft Allografts as Standalone Spinal Stabilization Devices 07/17/2018 07/17/2019
Breast Reconstruction Surgery and Prophylactic Mastectomy 09/11/2018 09/11/2019
Breast Reduction Surgery 01/16/2018 01/16/2019
Bronchial Thermoplasty 01/23/2018 01/23/2019
Cancer Chemotherapy Guidelines 03/20/2018 03/20/2019
Cancer Treatment Vaccines 06/26/2018 06/26/2019
Cerliponase alfa (Brineura) for Batten Disease 04/10/2018 04/10/2019
Chiropractic Services 05/22/2108 05/22/2019
Claim Review Process 05/15/2018 05/15/2019
Cochlear Implants and Auditory Brainstem Implants 02/20/2018 02/20/2019
Cold Therapy Devices 05/29/2018 05/29/2019
Computed Tomographic Colonography 01/30/2018 01/30/2019
Coverage Determination Review 08/22/2017 08/22/2018
Custodial Care 02/20/2018 02/20/2019
Deep Brain Stimulation 06/12/2018 06/12/2019
Dental Services 09/04/2018 09/04/2019
Dermatoscopy 02/27/2018 02/27/2019
Diathermy for Pain 02/20/2018 03/28/2019
Digital Breat Tomosynthesis 05/22/2018 05/22/2019
Discography 07/31/2018 07/31/2019
Durable Medical Equipment 05/29/2018 05/29/2019
Epidural Adhesiolysis 08/07/2018 08/07/2019
Eteplirsen (Exondys 51) for Muscular Dystrophy 01/16/2018 01/16/2019
External Counterpulsation/EECP 05/08/2018 05/08/2019
Extracorporeal Shock Wave Treatment 02/20/2018 02/20/2019
Gender Assignment and Reassignment Surgery 04/24/2018 04/24/2019
Genetic Testing 06/26/2018 06/26/2019
Gynecomastia Surgery 02/20/2018 02/20/2019
Heart Transplant Rejection Monitoring (AlloMap) 02/06/2018 02/06/2019
High Frequency Chest Wall Oscillation Vest 01/16/2018 01/16/2019
Hyperbaric Oxygen Therapy 04/03/2018 04/03/2019
Immune Globulin Therapy 01/23/2018 01/23/2019
Incontinence Alarms 06/26/2018 06/26/2019
Infertility/Assisted Reproductive Technology 04/17/2018 04/17/2019
Infliximab Biosimilar Products 03/06/2018 03/06/2019
Intensive Behavioral Therapy for Autism spectrum disorder (ABA) 01/30/2018 01/30/2019
Interspinous Process Decompression System (XStop®) 08/07/2018 08/07/2019
Intraoperative Neurophysiological Monitoring 04/24/2018 04/24/2019
Keratoconus and Medical Contact Lense 01/30/2018 01/30/2019
Preterm Early-Term Deliveries 08/14/2018 08/14/2019
Magnetic Sphincter Augmentation (Linx) for GERD 02/27/2018 02/27/2019
Medical Necessity Definition 01/23/2018 01/23/2019
Medical Necessity Determination 07/03/2018 07/03/2019
Medications Covered Under Medical Insurance Policy 01/23/2018 01/23/2019
Mobile Outpatient Cardiac Monitoring 01/16/2018 01/16/2019
Nerve Graft with Radical Prostatectomy 07/10/2018 07/10/2019
Neuromuscular Re-Education 03/06/2018 03/06/2019
Neuromuscular Stimulation 08/07/2018 08/07/2019
Neutralizing Antibody Testing in Multiple Sclerosis Patients 06/18/2018 06/18/2019
NICU Level of Care 09/25/2018 09/25/2019
Nitric Oxide Inh in Premature 08/14/2018 08/14/2019
Obstructive Sleep Apnea: Diagnosis and Treatment 04/17/2018 04/17/2019
Occipital Nerve Stimulation 04/03/2018 04/03/2019
Occupational Therapy 04/24/2018 04/24/2019
Off-Label Use of FDA Approved Drugs 05/08/2018 05/08/2019
Organ Transplantation 05/22/2018 05/22/2019
Orthoptic and Vision Therapy 01/30/2018 01/30/2019
Outpatient Pulmonary Rehabilitation 07/03/2018 07/03/2019
Panniculectomy - Removal of Redundant Tissue 07/10/2018 07/10/2019
Peer-to-Peer (P2P) Opportunity 01/30/2018 01/30/2019
Peroral Endoscopic Myotomy for Esophageal Achalasia (POEM) 01/23/2018 01/23/2019
Phototherapy (Non-Neonatal) 03/06/2018 03/06/2019
Physical Therapy 01/23/2018 01/23/2019
Private Duty Nursing 03/06/2018 03/06/2019
Prolotherapy 01/16/2018 01/16/2019
Proton Beam Radiation Therapy 03/20/2018 03/20/2019
Psychologic Evaluation for Medical Procedures 02/06/2018 02/06/2019
Psychological Testing 02/06/2018 02/06/2019
Pulsed Dye Laser Treatment 04/03/2018 04/03/2019
Regional Cerebral Blood Flow via Implanted Cerebral Thermal Perfusion Probe 07/03/2018 07/03/2019
Regional Sympathetic Blocks 08/07/2018 08/07/2019
Seizure Disorders: Invasive Treatments (Epilepsy Surgery) 06/05/2018 06/05/2019
Sipuleucel-T (Provenge) 03/13/2018 03/13/2019
Speech Therapy 05/22/2018 05/22/2019
Spinraza (Nusinersen) 06/12/2018 06/12/2019
Synagis (Palivizumab) 03/20/2018 03/20/2019
Talimogene Laherparepvec (Imlygic) 03/13/2018 03/13/2019
Tech Assess of Tests and Assays for Response to Agents 10/22/2015 10/22/2016
Transcatheter Aortic Valve 10/17/2017 10/17/2018
Transcranial Magnetic Stimulation for Depression 10/10/2017 10/10/2018
Transoral Fundoplication 01/23/2018 01/23/2019
Trigger Point Injections 07/17/2018 07/17/2019
Urinary Incontinence Treatments 03/13/2018 03/13/2019
Vagus Nerve Stimulation 08/18/2016 08/18/2017
Ventricular Assist Devices (VAD) 01/16/2018 01/16/2019
Vertebroplasty Kyphoplasty Sacroplasty 08/07/2018 08/07/2019
Vitamin Assays 01/16/2018 01/16/2019
Voretigene Neparvovec-rzyl (Luxturna) 06/26/2018 06/26/2019
Xofigo 02/27/2018 02/27/2019