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Medical & Drug Policies and Coverage Determination Guidelines - Commercial
 A Return to Top 
17-alpha-hydroxyprogesterone caproate (17P and MakenaTM) 
Ablative Treatment for Spinal Pain 
Abnormal Uterine Bleeding and Uterine Fibroids 
Actemra (tocilizumab) 
Alemtuzumab 
Ambulance Services 
Anemia Drugs: darbepoetin alfa and epoetin alfa 
Apheresis 
Athletic Pubalgia Surgery 
Attended Polysomnography for Evaluation of Sleep Disorders 
Autologous Chondrocyte Transplantation In The Knee 
 B Return to Top 
Balloon Sinus Ostial Dilation 
Bariatric Surgery 
Benlysta (belimumab) 
Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair 
Bone or Soft Tissue Healing and Fusion Enhancement Products 
Botulinum Toxin A and B 
Breast Imaging for Screening and Diagnosing Cancer 
Breast Reconstruction Post-Mastectomy 
Breast Reduction Surgery 
Breast Repair/Reconstruction Not Following Mastectomy 
Bronchial Thermoplasty 
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Cardiovascular Disease Risk Tests 
Chelation Therapy for Non-Overload Conditions 
Chemosensitivity and Chemoresistance Assays in Cancer 
Chemotherapy Observation and Inpatient Hospitalization 
Chromosome Microarray Testing 
Clinical Trials 
Clotting Factors and Coagulant Blood Products 
Cochlear Implants 
Cognitive Rehabilitation 
Collagen Crosslinks and Biochemical Markers of Bone Turnover 
Computed Tomographic Colonography 
Computerized Dynamic Posturography 
Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes 
Core Decompression For Avascular Necrosis 
Corneal Hysteresis and Intraocular Pressure Measurement 
Cosmetic and Reconstructive Procedures 
Custodial and Skilled Care Services 
Cytological Examination of Breast Fluids for Cancer Screening 
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Deep Brain Stimulation 
Discogenic Pain, Treatment 
Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies, and Repairs/Replacements 
 E Return to Top 
Elbow Replacement Surgery (Arthroplasty) 
Electrical Bioimpedance for Cardiac Output Measurement 
Electrical Stimulation and Electromagnetic Therapy for Wounds 
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation 
Electrical and Ultrasound Bone Growth Stimulators 
Emergency Health Services and Urgent Care Center Services 
Entyvio (vedolizumab) 
Enzyme Replacement Therapy for Gaucher Disease 
Epidural Steroid and Facet Injections for Spinal Pain 
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography 
Extracorporeal Shock Wave Therapy (ESWT) 
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Fecal Calprotectin Testing 
Fecal DNA Testing 
Femoroacetabular Impingement Syndrome 
Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood 
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Gait Analysis 
Gastrointestinal Motility Disorders, Diagnosis and Treatment 
Gender Identity Disorder/Gender Dysphoria Treatment 
Gene Expression Tests 
Genetic Testing 
Genetic Testing for Hereditary Breast Ovarian Cancer Syndrome (HBOC) 
Glaucoma Surgical Treatment 
Gynecomastia Treatment 
 H Return to Top 
H.P. Acthar Gel (repository corticotropin injection) 
Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable 
Hepatitis Screening 
Hereditary Angioedema (HAE), Treatment and Prophylaxis 
High-Frequency Chest Wall Compression Devices 
Hip Replacement Surgery (Arthroplasty) 
Hip Resurfacing Arthroplasty 
Home Health Care 
Home Hemodialysis 
Home Traction Therapy 
Hospital Readmissions 
Hysterectomy for Benign Conditions 
 I Return to Top 
Immune Globulin (IVIG and SCIG) 
Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion 
Implantable Beta-Emitting Microspheres For Treatment Of Malignant Tumors 
Implanted Electrical Stimulator for Spinal Cord 
In Utero Fetal Surgery 
Infertility Diagnosis and Treatment 
Inpatient Pediatric Feeding Programs 
Intensity-Modulated Radiation Therapy 
Intensive Behavioral Therapy for Autism Spectrum Disorders 
Intermittent Intravenous Insulin Therapy 
Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) 
 J Return to Top 
 K Return to Top 
Knee Replacement Surgery (Arthroplasty) 
 L Return to Top 
Light and Laser Therapy for Cutaneous Lesions and Pilonidal Disease 
Lithotripsy for Salivary Stones 
Lupron Depot /Lupron Depot-Ped (leuprolide acetate) for Non-Oncology Use 
Lyme Disease 
 M Return to Top 
Macular Degeneration Treatment Procedures 
Magnetic Resonance Spectroscopy (MRS) 
Magnetoencephalography And Magnetic Source Imaging For Specific Neurological Applications 
Manipulation Under Anesthesia 
Manipulative Therapy 
Maximum Dosage Policy 
Mechanical Stretching and Continuous Passive Motion Devices 
Meniscus Implant and Allograft 
Mifeprex mifepristone Policy 
Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) 
Motorized Spinal Traction 
 N Return to Top 
Nerve Graft to Restore Erectile Function During Radical Prostatectomy 
Neurophysiologic Testing 
Neuropsychological Testing Under the Medical Benefit 
 O Return to Top 
Obstructive Sleep Apnea Treatment 
Occipital Neuralgia and Headache Treatment 
Off-Label/Unproven Specialty Drug Treatment 
Omnibus Codes 
Oncology Medication Clinical Coverage Policy 
Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors 
Orencia (abatacept) 
Orthognathic/Jaw Surgery 
Oscillatory Positive Expiratory Pressure Devices 
Osteochondral Grafting of Knee 
Outpatient Cardiovascular Telemetry 
 P Return to Top 
Panniculectomy and Body Contouring Procedures 
Pectus Deformity Repair 
Plagiocephaly and Craniosynostosis Treatment 
Platelet Derived Growth Factors for Treatment of Wounds 
Pneumatic Compression Devices 
Presacral Neurectomy and Uterine Nerve Ablation for Pelvic Pain 
Preterm Labor: Identification and Treatment 
Preventive Care Services 
Preventive Care Services Coding Guideline Summary 
Private Duty Nursing 
Prolotherapy for Musculoskeletal Indications 
Propranolol Treatment for Infantile Hemangiomas: Inpatient Protocol 
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs 
Proton Beam Radiation Therapy 
 Q Return to Top 
 R Return to Top 
Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Incontinence 
Remicade (infliximab) 
Rhinoplasty and Other Nasal Surgeries 
Rituxan (rituximab) 
 S Return to Top 
Sandostatin/Sandostatin LAR Depot (octreotide acetate) 
Sensory Integration Therapy and Auditory Integration Training 
Shoulder Replacement Surgery (Arthroplasty) 
Simponi Aria (Golimumab) 
Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Specialty Medication Infusion 
Skilled Care and Custodial Care Services 
Sodium Hyaluronate 
Soliris (Eculizumab) 
Speech-Language Pathology Services 
Spinal Ultrasonography 
Standing Systems 
Stelara (ustekinumab) 
Surgical Treatment for Spine Pain 
Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins 
Synagis Policy 
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Temporomandibular Joint Disorders 
Thermal Capsulorrhaphy/Thermal Shrinkage Therapy 
Thermography 
Total Artificial Disc Replacement for the Spine 
Total Artificial Heart 
Transcatheter Heart Valve Procedures 
Transcranial Magnetic Stimulation 
Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Nausea and Vomiting 
Transpupillary Thermotherapy 
Tysabri Policy 
 U Return to Top 
Umbilical Cord Blood Harvesting and Storage for Future Use 
Unicondylar Spacer Devices For Treatment Of Pain Or Disability 
 V Return to Top 
Vaccine policy 
Vagus Nerve Stimulation 
Vimizim (Elosulfase Alfa) 
Virtual Upper Gastrointestinal Endoscopy 
Visual Information Processing Evaluation and Orthoptic and Vision Therapy 
 W Return to Top 
Warming Therapy and Ultrasound Therapy for Wounds 
Wearable Cardioverter-Defibrillators 
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Xolair policy 
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 Z Return to Top