Medical & Drug Policies and Coverage Determination Guidelines - Commercial
 Update Bulletin Back to Top 
01/01/17 - Medical Policy Update Bulletin: January 2017 
02/01/17 - Medical Policy Update Bulletin: February 2017 
03/01/17 - Medical Policy Update Bulletin: March 2017 
04/01/17 - Medical Policy Update Bulletin: April 2017 
05/01/17 - Medical Policy Update Bulletin: May 2017 
06/01/17 - Medical Policy Update Bulletin: June 2017 
07/01/17 - Medical Policy Update Bulletin: July 2017 
08/01/17 - Medical Policy Update Bulletin: August 2017 (Updated) 
Archives - Medical Policy Update Bulletin: 2015 Archives 
Archives - Medical Policy Update Bulletin: 2016 Archives 
 A Back to Top 
17-Alpha-Hydroxyprogesterone Caproate (Makena and 17P) 
Ablative Treatment for Spinal Pain 
Abnormal Uterine Bleeding and Uterine Fibroids 
Actemra (Tocilizumab) Injection for Intravenous Infusion 
Ambulance Services 
Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa, and Methoxy Polyethylene Glycol-Epoetin Beta 
Athletic Pubalgia Surgery 
Attended Polysomnography for Evaluation of Sleep Disorders 
Autologous Chondrocyte Transplantation in the Knee 
 B Back 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 Toxins 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 
 C Back to Top 
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 
Cytological Examination of Breast Fluids for Cancer Screening 
 D Back to Top 
Deep Brain and Cortical Stimulation 
Discogenic Pain Treatment 
Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements 
 E Back to Top 
Elbow Replacement Surgery (Arthroplasty) 
Electric Tumor Treatment Field Therapy 
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 
Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome 
Emergency Health Services and Urgent Care Center Services 
Entyvio (Vedolizumab) 
Epidural Steroid and Facet Injections for Spinal Pain 
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography 
Exondys 51 (Eteplirsen) 
Extracorporeal Shock Wave Therapy (ESWT) 
 F Back to Top 
Fecal Calprotectin Testing 
Femoroacetabular Impingement Syndrome 
Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood 
Functional Endoscopic Sinus Surgery (FESS) 
 G Back to Top 
Gait Analysis 
Gastrointestinal Motility Disorders, Diagnosis and Treatment 
Gender Dysphoria Treatment 
Gene Expression Tests 
Genetic Testing 
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC) 
Glaucoma Surgical Treatments 
Gonadotropin Releasing Hormone Analogs 
Gynecomastia Treatment 
 H Back to Top 
Habilitative Services for Essential Health Groups 
Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable 
Helicobacter Pylori Serology Testing 
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 Back 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 
Infertility Diagnosis and Treatment 
Infertility Services 
Infliximab (Remicade and Inflectra) 
Inpatient Pediatric Feeding Programs 
Intensity-Modulated Radiation Therapy 
Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) 
Intrauterine Fetal Surgery 
Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease 
 J Back to Top 
 K Back to Top 
 L Back to Top 
Lemtrada (Alemtuzumab) 
Light and Laser Therapy for Cutaneous Lesions and Pilonidal Disease 
Lithotripsy for Salivary Stones 
Lyme Disease 
 M Back 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 
Mechanical Stretching Devices 
Meniscus Implant and Allograft 
Mifeprex (Mifepristone) 
Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) 
Molecular Profiling to Guide Cancer Treatment 
Motorized Spinal Traction 
 N Back to Top 
Nerve Graft to Restore Erectile Function During Radical Prostatectomy 
Neurophysiologic Testing 
Neuropsychological Testing Under the Medical Benefit 
 O Back to Top 
Obstructive Sleep Apnea Treatment 
Occipital Neuralgia and Headache Treatment 
Ocrevus (Ocrelizumab) 
Off-Label/Unproven Specialty Drug Treatment 
Office Based Program 
Omnibus Codes 
Oncology Medication Clinical Coverage 
Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors 
Orencia (Abatacept) Injection for Intravenous Infusion 
Orthognathic (Jaw) Surgery 
Osteochondral Grafting of Knee 
Outpatient Cardiovascular Telemetry 
 P Back to Top 
Panniculectomy and Body Contouring Procedures 
Pectus Deformity Repair 
Percutaneous Vertebroplasty and Kyphoplasty 
Plagiocephaly and Craniosynostosis Treatment 
Platelet Derived Growth Factors for Treatment of Wounds 
Pneumatic Compression Devices 
Preterm Labor Management 
Preventive Care Services 
Private Duty Nursing Services (PDN) 
Probuphine (Buprenorphine) 
Prolotherapy for Musculoskeletal Indications 
Propranolol Treatment for Infantile Hemangiomas: Inpatient Protocol 
Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs 
Proton Beam Radiation Therapy 
 Q Back to Top 
 R Back to Top 
Rehabilitation Services (Outpatient) 
Repository Corticotropin Injection (H.P. Acthar Gel) 
Respiratory Interleukins (IL) 
Rhinoplasty and Other Nasal Surgeries 
Rituxan (Rituximab) 
 S Back to Top 
Sandostatin/Sandostatin LAR Depot (Octreotide Acetate) 
Sensory Integration Therapy and Auditory Integration Training 
Shoulder Replacement Surgery (Arthroplasty) 
Simponi Aria (Golimumab) Injection for Intravenous Infusion 
Site of Service Guidelines for Certain Outpatient Surgical Procedures 
Skilled Care and Custodial Care Services 
Sodium Hyaluronate 
Soliris (Eculizumab) 
Specialty Medication Administration-Site of Care Review Guidelines 
Speech Language Pathology Services 
Spinal Ultrasonography 
Spinraza (Nusinersen) 
Standing Systems and Gait Trainers 
Stelara (Ustekinumab) 
Surgical Treatment for Spine Pain 
Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins 
Synagis (Palivizumab) 
 T Back to Top 
Temporomandibular Joint Disorders 
Thermal Capsulorrhaphy/Thermal Shrinkage Therapy 
Total Artificial Disc Replacement for the Spine 
Total Artificial Heart 
Total Knee Replacement Surgery (Arthroplasty) 
Transcatheter Heart Valve Procedures 
Transcranial Magnetic Stimulation 
Transpupillary Thermotherapy 
 U Back to Top 
Umbilical Cord Blood Harvesting and Storage for Future Use 
Unicondylar Spacer Devices for Treatment of Pain or Disability 
 V Back to Top 
Vagus Nerve Stimulation 
Vimizim (Elosulfase Alfa) 
Virtual Upper Gastrointestinal Endoscopy 
Visual Information Processing Evaluation and Orthoptic and Vision Therapy 
 W Back to Top 
Warming Therapy and Ultrasound Therapy for Wounds 
Wearable Cardioverter-Defibrillators 
 X Back to Top 
Xolair (Omalizumab) 
 Y Back to Top 
 Z Back to Top