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Medical & Drug Policies and Coverage Determination Guidelines
 A Return to Top 
17-alpha-hydroxyprogesterone caproate (17P and MakenaTM) 
Ablative Treatment for Spinal Pain 
Abnormal Uterine Bleeding and Uterine Fibroids 
Actemra (tocilizumab) 
Ambulance Services 
Anemia Drugs: darbepoetin alfa and epoetin alfa 
Apheresis 
Athletic Pubalgia Surgery 
Autism Spectrum Disorder 
Autologous Chondrocyte Transplantation In The Knee 
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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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Campath Policy 
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 
Cost Effective Review (Least Costly, Medically Necessary, Medical Necessity, Reasonable and Necessary) 
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 
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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 
Epidural Steroid and Facet Injections for Spinal Pain 
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography 
Erbitux Policy 
Extracorporeal Shock Wave Therapy (ESWT) for Orthopedic Indications 
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Fecal Calprotectin Testing 
Fecal DNA Testing 
Femoroacetabular Impingement Syndrome 
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Gait Analysis 
Gastrointestinal Motility Disorders, Diagnosis and Treatment 
Gaucher Disease 
Gender Identity Disorder (Sex Transformation) 
Gene Expression Tests 
Genetic Testing for Hereditary Breast Ovarian Cancer Syndrome (HBOC) 
Glaucoma Surgical Treatment 
Gynecomastia Treatment 
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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 Hemodialysis 
Home Traction Therapy 
Hospital Readmissions Quality of Care Guideline (QOC) 
Human Epidermal Growth Factor Receptor 2 (HER2) Targeting Drugs Policy 
Human Immunodeficiency Virus (HIV) Tropism Testing 
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Immune Globulin (IVIG and SCIG) 
Implantable Beta-Emitting Microspheres For Treatment Of Malignant Tumors 
Implanted Electrical Stimulator for Spinal Cords 
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 
Intrastromal Corneal Ring Segments 
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 K Return to Top 
Knee Replacement Surgery (Arthroplasty) 
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Laser Therapy for Cutaneous Vascular Lesions and Pilonidal Disease 
Lithotripsy for Salivary Stones 
Lupron Depot /Lupron Depot-Ped (leuprolide acetate) for Non-Oncology Use 
Lyme Disease 
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Macular Degeneration and Ocular Tumor Treatment 
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 
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Nerve Graft to Restore Erectile Function During Radical Prostatectomy 
Neurophysiologic Testing 
Neuropsychological Testing Under the Medical Benefit 
Non-Surgical Treatment of Obstructive Sleep Apnea 
Noninvasive Prenatal Diagnosis of Fetal Aneuploidy Using Cell-Free Fetal Nucleic Acids in Maternal Blood 
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Occipital Neuralgia and Cervicogenic, Cluster and Migraine Headaches 
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 
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Panniculectomy and Body Contouring Procedures 
Pectus Deformity Repair 
Plagiocephaly and Craniosynostosis Treatment 
Platelet Derived Growth Factors for Treatment of Wounds 
Pneumatic Compression Devices 
Polysomnography and Portable Monitoring for Evaluation of Sleep Related Breathing Disorders 
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 and Wigs 
Proton Beam Radiation Therapy 
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Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary Incontinence 
Remicade (infliximab) 
Rhinoplasty, Septoplasty, and Repair of Vestibular Stenosis 
Rituxan (rituximab) 
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Sandostatin/Sandostatin LAR (octreotide acetate) 
Sensory Integration Therapy and Auditory Integration Training 
Shoulder Replacement Surgery (Arthroplasty) 
Sodium Hyaluronate 
Specialized, Microprocessor or Myoelectric Limbs 
Speech-Language Pathology Services 
Spinal Ultrasonography 
Standing Systems 
Stelara (ustekinumab) 
Surgical Treatment for Spine Pain 
Surgical Treatment of Obstructive Sleep Apnea 
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 
Transtympanic Micropressure 
Tysabri Policy 
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Umbilical Cord Blood Harvesting and Storage for Future Use 
Unicondylar Spacer Devices For Treatment Of Pain Or Disability 
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Vaccine policy 
Vagus Nerve Stimulation 
Virtual Upper Gastrointestinal Endoscopy 
Visual Information Processing Evaluation and Orthoptic and Vision Therapy 
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Warming Therapy and Ultrasound Therapy for Wounds 
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Xolair policy 
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