Medical Policies

Medical Policies are listed in alphabetical order


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Abraxane® (paclitaxel protein-bound particles) - New: 4/11/17
Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy
Alimta® (pemetrexed) - New: 4/11/17
AlloMap® Molecular Expression Testing for Post-Heart-Transplant Rejection
Aloxi® (palonosetron) - New: 4/11/17
Alpha-1-Proteinase Inhibitors Infusion Therapy
Amniotic Membrane Transplantation for Ocular Reconstruction
Analysis of KRAS Status
Arthroscopy for the Osteoarthritic knee
Artificial Intervertebral Discs
Assisted Reproductive Technologies - Revised: 4/21/17
Autologous Chondrocyte Implantation  
Automatic External Defibrillators
Avastin® (bevacizumab) (Intravenous) - New: 4/11/17
Azacitidine (Vidaza®)
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Balloon Sinuplasty
Bariatric Surgery
BCR-ABL1 Genetic Mutation Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia
Benlysta (belimumab) - 03/27/2017
Blinatumomab (Blincyto™)
Biomagnetic Therapy
Bone-Anchored Hearing Aids - Revised: 3/10/17
Bone Mineral Density Studies in Adult Populations 
BRAF Mutation Analysis
BRCA 1 and 2 Genetic Testing (Sequence Analysis/Rearrangement)
Breast Implants and Reconstruction
Breast Reduction Mammoplasty
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Campath® (Alemtuzumab) - Revised: 4/21/17
Canaloplasty and Viscocanalostomy
Capsule Endoscopy (camera pill)
Cardiac Event Monitors - Revised: 4/21/17
Cardiac Ion Channel Genetic Testing
Cardiac Resynchronization Therapy (Biventricular Pacing)
Carrier Screening for Parents or Prospective Parents
Chelation Therapy
Chemical Peels
Chromosomal Microarray Analysis (CMA)
Cimzia® (certolizumab pegol) - New: 3/24/17
Cognitive Rehabilitation
Continuous Passive Motion Devices
Cosmetic Surgery Procedures
Cranial Helmets for Plagiocephaly and Prevention of Head Injury
Cryosurgical and Radiofrequency Ablation for Renal Tumors 
Cryosurgery for Liver Tumors 
Cryosurgical Ablation for Prostate Cancer
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Deep Brain Stimulation
Dorsal Column Stimulator for Pain Management - Revised: 3/13/17
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Endoscopic and Percutaneous Lysis of Epidural Adhesions (RACZ Procedure) — MEDICARE ONLY
Entyvio (vedolizumab) - New 3/24/17
Enzyme Replacement Infusion Therapy.
Epidermal Growth Factor Receptor Mutation Analysis for Patients with Non-Small-Cell Lung Cancer
Erbitux® (cetuximab) - New: 4/11/17
Erythropoiesis Stimulating Agents (ESAs): Aranesp® (darbepoetin alfa) - New: 4/11/17
Erythropoiesis Stimulating Agents (ESAs): Epogen/Procrit® - New: 4/11/17
Eteplirsen (Exondys 51™)
External Breast Prosthesis /Bra
External Counterpulsation
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Fecal Incontinence Treatment
Fecal microbiota transplant (FMT) for Recurrent Clostridium difficile Infection
Functional Endoscopic Sinus Surgery (FESS)
Fusilev (levoleucovorin) - New 3/27/2017
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Gastric Electrical Stimulation
Gender Reassignment Surgery - Revised 2/10/17
Gene Expression Profile Testing for Multiple Myeloma
Gene Expression Profiling - Revised: 4/21/17
Gene Expression Profiling and Biomarker Testing for Breast Cancer - Revised 2/10/17
Gene Expression Profiling of Melanomas
Genetic Analysis of PIK3CA Status in Tumor Cells
Genetic Counseling and Testing
Genetic Testing for Alzheimer’s Disease
Genetic Testing for Cancer Susceptibility - New: 3/10/17
Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome - Revised 2/10/17
Genetic Testing for Colorectal Cancer / Lynch Syndrome
Genetic Testing for Cystic Fibrosis
Genetic Testing for Factor V Leiden Mutation Analysis
Genetic Testing for Frontotemporal Dementia (FTD)
Genetic Testing for Inherited Peripheral Neuropathies
Genetic Testing for Hereditary Cardiomyopathy
Genetic Testing for Hereditary Hemochromatosis
Genetic Testing for Hereditary Pancreatitis
Genetic Testing for PTEN Hamartoma Tumor Syndrome
Genetic Testing for RET Proto-Oncogene Germline Point Mutation
Genetic Testing for Statin-Induced Myopathy
Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome)
Glaucoma Surgery
Granulocyte Colony Stimulating Factors 
Gynecomastia Surgery
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H.P. Acthar® Gel
Halaven™ (eribulin) - New: 3/27/17
Hemophilia Infusion Therapy
Herceptin® (trastuzumab) - New: 4/11/17
Hereditary Angioedema Drugs
High Frequency Chest Wall Oscillation Devices and Intrapulmonary Percussive Ventilators
Home Birth Midwifery Services
Home Pulse Oximetry for Infants and Children
Home Uterine Activity Monitoring
Hyaluronate Injections for Osteoarthritis of the Knee — COMMERICAL and MEDICARE
Hydroxyprogesterone Caproate (Makena®) for the Prevention of Preterm Labor
Hyperbaric Oxygen Therapy
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Idiopathic Environmental Intolerance (IEI)
Ilizarov Technique
Implantable Cardioverter Defibrillators
Infertility Services
Infliximab Injectable (Inflectra®, Remicade®) - Revised: 4/1/17
Insulin Delivery Devices and Continuous Glucose Monitoring Systems - Revised: 4/7/17
Intensive Behavioral Therapy for Obesity
Intravenous Immune Globulins (immune globulin) - New: 3/24/17
Interspinous Distraction Devices
Intrathecal Baclofen for CNS Spasticity
Intravitreal Injections/Implants
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Janus Kinase 2 (JAK2) V617F Gene Mutation Assay
Jevtana (cabazitaxel) - New 3/24/17
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Kadcyla® (ado-trastuzumab emtansine) - New 3/24/17
Keytruda® (pembrolizumab)
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Lemtrada® (alemtuzumab)
Lipoprotein Subclassification Testing for Screening, Evaluation and Monitoring of Cardiovascular Disease
Level of Care (LOC) -- Ambulatory Surgical Procedures
Lung Volume Reduction Surgery
Lumbar Fusion and Intervertebral Fusion Devices - Revised: 3/10/17
Lyme Disease Diagnosis and Treatment
Lymphedema Treatment
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Magnetoencephalography-Magnetic Source Imaging
Mechanical Stretching Devices
Medical Necessity Guidelines for Non-Covered Investigational Services
Metal on Metal Hip Resurfacing
Metoclopramide and Ondansetron Infusion for Hyperemesis Gravidarum - Revised: 4/21/17
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Nasal Spray Flu Vaccine
Neuropsychological Testing - Revised: 5/12/17
Neurotoxins (Botox®, Dysport®, Myobloc® and Xeomin®)
Nplate (romiplostim) - New 3/27/17
Non-invasive H pylori Testing
Non-invasive Prenatal Testing (NIPT) for Fetal Aneuploidy
Noncoronary Vascular Stents
Nuchal Translucency Screening for Down Syndrome
Nutritional Counseling Services
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Obstetric Ultrasonography
Obstructive Sleep Apnea Diagnosis and Treatment - Revised: 3/10/17
Off-Label Use of FDA-Approved Drugs and Biologicals
Omalizumab (Xolair®)
Opdivo® (nivolumab)
Orthognathic Surgery
Orthopedic Footwear
Osteochondral Grafting
Osteogenesis Stimulators
Otoacoustic Emission Testing for Pediatric Populations in the Primary Care Setting
Outpatient Cardiac Rehabilitation
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Pain Management
Pancreatic Islet Cell Transplantation for Chronic Pancreatitis
Pasireotide (Signifor® LAR)
Peripheral Nerve Blocks - New: 4/21/17
Periurethral Bulking Agents for Urinary Incontinence
Perjeta (pertuzumab)New: 3/27/17
Phototherapy, Photochemotherapy and Photodynamic Therapy for Dermatologic Conditions - Revised: 2/10/17
Prolia®/Xgeva® (denosumab) - New: 3/27/17
Prostatic Urethral Lift (PUL) — MEDICARE
PROVENGE® (sipuleucel-T)
Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions
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Radiofrequency Ablation for Tumors - Revised: 5/12/17
Radiofrequency Ablation for Barrett’s Esophagus
Radiofrequency Ablation for Spinal Pain
Recurrent Pregnancy Loss
Risk-Reduction Mastectomy
Rituxan® (rituximab) - New: 4/11/17
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Sacroiliac Joint Fusion
Sandostatin® LAR (octreotide) - New: 4/11/17
Selective Dorsal Rhizotomy for Cerebral Palsy
Selective Internal Radiation Therapy
Soliris® (eculizumab) - New: 4/11/17
Specialty Outpatient Day-Hospital Services
Speech-Language Pathology - Interventional Services for Autism Spectrum Disorders
Spinraza™ (Nusinersen) - New: 4/13/17
Stelara® (ustekinumab) - New: 3/24/17
Subcutaneous immune globulins (SCIG): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia, Cuvitru - New: 3/24/17
Surgical Correction of Chest Wall Deformities
Stereotactic Radiosurgery and Proton Beam Therapy
Sympathectomy for Hyperhidrosis
Synagis® (Palivizumab)
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Therapeutic Shoes for Diabetics
Topical Oxygen Wound Therapy (Medicaid/FHP)
Total Ankle Replacement
Transcatheter Aortic Valve Replacement
Transcranial Magnetic Stimulation for Major Depressive Disorder
Transurethral Radiofrequency Micro-Remodeling for Female Stress Urinary Incontinence
Tysabri (natalizumab) - New 3/27/17
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Vacuum-Assisted Wound Closure - Revised: 2/10/17
Vagus Nerve Stimulation for Epilepsy
Vantas® (histrelin acetate) - New: 4/11/17
Varicose Vein Treatment
Vectibix® (panitumumab) - New: 4/11/17
Vertical Expandable Prosthetic Titanium Rib (VEPTR) - New: 3/10/17
Virtual Colonoscopy (CT colonography)
Visual Evoked Potential Testing for Pediatric Populations in the Primary Care Setting
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Wigs — MEDICAID/FHP/EPO Direct Pay (Bronze, Silver, Gold, Platinum)
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Xofigo for Castration-Resistant Prostate Cancer
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Yervoy™ (ipilimumab)
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Zoledronic acid (Zometa®, Reclast®) - New: 4/11/17