Medical Policies

Medical Policies are listed in alphabetical order

A|B|C|D|E|F|G|H|I|J|K|L|M|N|O|P|Q|R|S|T|U|V|W|X|Y|Z

A Download (PDF)
Abraxane® (paclitaxel protein-bound particles) Download (PDF)
Actemra (tocilizumab) Download (PDF)
Acupuncture — Medicare Dual-Eligible/Medicare VIP Essential - Revised 1/1/19 Download (PDF)
Akynzeo (fosnetupitant and palonosetron) Injection Download (PDF)
Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy Download (PDF)
Aldurazyme (laronidase) Download (PDF)
Alimta® (pemetrexed) Download (PDF)
Aliqopa™ (copanlisib) Download (PDF)
Aloxi® (palonosetron) Download (PDF)
Alpha-1-Proteinase Inhibitors Infusion Therapy Download (PDF)
Amniotic Membrane Transplantation for Ocular Reconstruction Download (PDF)
Analysis of KRAS Status Download (PDF)
Anesthesia for Dental Procedures and Oral and Maxillofacial Surgery — New York - New 12/14/18 Download (PDF)
Application of Bioengineered Skin Substitutes Download (PDF)
Artificial Intervertebral Discs Download (PDF)
Assisted Reproductive Technologies Download (PDF)
Autologous Chondrocyte Implantation Download (PDF)
Automatic Blood Pressure Monitor - New 1/11/19 Download (PDF)
Automatic External Defibrillators Download (PDF)
Avastin® (bevacizumab) (Intravenous) Download (PDF)
Azacitidine (Vidaza®) Download (PDF)
Azedra® (Iobenguane I-131) - New 1/1/19 Download (PDF)


B Download (PDF)
Balloon Sinuplasty Download (PDF)
Bariatric Surgery Download (PDF)
Bavencio® (avelumab) Download (PDF)
Baxdela (delafloxacin) for Injection Download (PDF)
Benlysta (belimumab) Download (PDF)
Berinert (C1 Esterase Inhibitor Human) Download (PDF)
Besponsa® (inotuzumab ozogamicin) Download (PDF)
Biomagnetic Therapy Download (PDF)
Blepharoplasty - Revised 1/11/19 Download (PDF)
Blinatumomab (Blincyto™) Download (PDF)
Bone-Anchored Hearing Aids Download (PDF)
Bone Mineral Density Studies in Adult Populations Download (PDF)
BRAF Mutation Analysis Download (PDF)
BRCA 1 and 2 Genetic Testing (Sequence Analysis/Rearrangement) Download (PDF)
Breast Implants and Reconstruction Download (PDF)
Breast Reduction Mammoplasty Download (PDF)
Brineura (cerliponase alfa) Download (PDF)
C Download (PDF)
Campath® (Alemtuzumab) Download (PDF)
Canaloplasty and Viscocanalostomy Download (PDF)
Capsule Endoscopy (camera pill) Download (PDF)
Cardiac Event Monitors Download (PDF)
Carrier Screening for Parents or Prospective Parents Download (PDF)
Cerezyme (imiglucerase) Download (PDF)
Chelation Therapy Download (PDF)
Chemical Peels Download (PDF)
Chromosomal Microarray Analysis (CMA) Download (PDF)
Cimzia® (certolizumab pegol) Download (PDF)
Cinryze (C1 Esterase Inhibitor Human) Download (PDF)
Cinvanti (aprepitant) Injectable Emulsion Download (PDF)
Clinical Trials/Experimental/Investigational Procedure/Treatments/Rare Disease Treatment — Commercial and Medicaid Download (PDF)
Clinical Trials — Medicare Download (PDF)
Clotting Disorder Therapy Download (PDF)
Cognitive Rehabilitation Download (PDF)
Colony Stimulating Factors: Fulphila™ (pegfilgrastim-jmdb) Download (PDF)
Colony Stimulating Factors: Nivestym™ (filgrastim-aafi) Download (PDF)
Colony Stimulating Factors: Udenyca (pegfilgrastim-cbqv) - New 1/1/19 Download (PDF)
Continuous Passive Motion Devices Download (PDF)
Cortical Stimulation for Epilepsy (NeuroPace®) Download (PDF)
Cosmetic Surgery Procedures Download (PDF)
Crysvita (burosumab-twza) Download (PDF)
Cyramza® (ramucirumab) Download (PDF)
Cryosurgery for Liver Tumors Download (PDF)
Cryosurgical and Radiofrequency Ablation for Renal Tumors  Download (PDF)
Cryosurgical Ablation for Prostate Cancer Download (PDF)
D Download (PDF)
Deep Brain Stimulation Download (PDF)
Dental Care or Treatment Necessary Due to Congenital Disease or Anomaly — New York - New 12/14/18 Download (PDF)
Dental Trauma Guidelines for Medical Plan - New 12/14/18 Download (PDF)
Dermabrasion Download (PDF)
Dorsal Column Stimulator for Pain Management Download (PDF)
E Download (PDF)
Elaprase® (idursulfase) Download (PDF)
Elelyso (taliglucerase alfa) Download (PDF)
Endoscopic and Percutaneous Lysis of Epidural Adhesions (RACZ Procedure) — MEDICARE ONLY Download (PDF)
Entyvio (vedolizumab) Download (PDF)
Erbitux® (cetuximab) Download (PDF)
Erythropoiesis Stimulating Agents (ESAs): Aranesp® (darbepoetin alfa) Download (PDF)
Erythropoiesis Stimulating Agents (ESAs): Epogen/Procrit® (epoetin alfa) Download (PDF)
Eteplirsen (Exondys 51™) Download (PDF)
External Breast Prosthesis /Bra Download (PDF)
F Download (PDF)
Fabrazyme (agalsidase beta) Download (PDF)
Fasenra™ (benralizumab) Download (PDF)
Fecal Incontinence Treatment Download (PDF)
Fecal microbiota transplant (FMT) for Recurrent Clostridium difficile Infection Download (PDF)
Firazyr (icatibant) Download (PDF)
Functional Endoscopic Sinus Surgery (FESS) Download (PDF)
Fusilev (levoleucovorin) Download (PDF)
G Download (PDF)
Gastric Electrical Stimulation Download (PDF)
Gender Affirming/Reassignment Surgery — New York - Revised 12/14/18 Download (PDF)
Gene Expression Profile Testing for Multiple Myeloma Download (PDF)
Gene Expression Profiling - Revised: 2/8/19 Download (PDF)
Gene Expression Profiling and Biomarker Testing for Breast Cancer Download (PDF)
Genetic Analysis of PIK3CA Status in Tumor Cells Download (PDF)
Genetic Counseling and Testing Download (PDF)
Genetic Testing for Alzheimer’s Disease Download (PDF)
Genetic Testing for Cancer Susceptibility Download (PDF)
Genetic Testing for Colorectal Cancer / Lynch Syndrome Download (PDF)
Genetic Testing for Frontotemporal Dementia (FTD) Download (PDF)
Genetic Testing for Hereditary Cardiomyopathy Download (PDF)
Genetic Testing for Hereditary Pancreatitis Download (PDF)
Genetic Testing for PTEN Hamartoma Tumor Syndrome Download (PDF)
Genetic Testing for Statin-Induced Myopathy Download (PDF)
Glaucoma Surgery - Revised 12/14/18 Download (PDF)
H Download (PDF)
H.P. Acthar® Gel Download (PDF)
Halaven™ (eribulin) Download (PDF)
Herceptin® (trastuzumab) Download (PDF)
High Frequency Chest Wall Oscillation Devices and Intrapulmonary Percussive Ventilators Download (PDF)
Home Birth Midwifery Services Download (PDF)
Home Pulse Oximetry for Infants and Children Download (PDF)
Home Uterine Activity Monitoring Download (PDF)
Hyaluronate Injections for Osteoarthritis of the Knee — COMMERICAL and MEDICARE Download (PDF)
Hydroxyprogesterone Caproate (Makena®) for the Prevention of Preterm Labor Download (PDF)
Hyperbaric Oxygen Therapy Download (PDF)
Hyperthermia Treatment for Cancer Download (PDF)
Hysterectomy Download (PDF)
I Download (PDF)
Idiopathic Environmental Intolerance (IEI) Download (PDF)
Ilizarov Technique Download (PDF)
Ilumya (tildrakizumab-asmn) Download (PDF)
Imfinzi™ (durvalumab) Download (PDF)
Implantable Cardioverter Defibrillators Download (PDF)
Infertility Services Download (PDF)
Infliximab Injectable (Inflectra®, Remicade®, Renflexis™) Download (PDF)
Insulin Delivery Devices and Continuous Glucose Monitoring Systems Download (PDF)
Interspinous Distraction Devices Download (PDF)
Intrastromal Corneal Ring Segments for Keratoconus Download (PDF)
Intravenous Immune Globulins (immune globulin) Download (PDF)
Intravitreal Injections/Implants Download (PDF)
J Download (PDF)
Jevtana (cabazitaxel) Download (PDF)
K Download (PDF)
Kadcyla® (ado-trastuzumab emtansine) Download (PDF)
Kalbitor (ecallantide) Download (PDF)
Keytruda® (pembrolizumab) Download (PDF)
Krystexxa (pegloticase) Download (PDF)
Kymriah™ (tisagenlecleucel) Download (PDF)
Kyprolis (carfilzomib) Download (PDF)
L Download (PDF)
Lartruvo (olaratumab) Download (PDF)
Lemtrada® (alemtuzumab) Download (PDF)
Leukine® (sargramostim) Download (PDF)
Lipoprotein Subclassification Testing for Screening, Evaluation and Monitoring of Cardiovascular Disease Download (PDF)
Lumbar Fusion and Intervertebral Fusion Devices Download (PDF)
Lumizyme (alglucosidase alfa) Download (PDF)
Lung Volume Reduction Surgery Download (PDF)
Lutathera® (lutetium Lu 177 dotatate) Download (PDF)
Luxturna™ (Voretigene neparvovec) — Medicaid  Download (PDF)
Lyme Disease Diagnosis and Treatment  Download (PDF)
Lymphedema Treatment Download (PDF)
M Download (PDF)
Marqibo® (vincristine sulfate liposomal) Download (PDF)
Mechanical Stretching Devices Download (PDF)
Medical Necessity Guidelines for Non-Covered Investigational Services Download (PDF)
Mepsevii (vestronidase alfa-vjbk) - New 1/1/19 Download (PDF)
Metoclopramide and Ondansetron Infusion for Hyperemesis Gravidarum Download (PDF)
Mvasi (bevacizumab-awwb) - New 1/1/19 Download (PDF)
MYvantage® Hereditary Comprehensive Cancer Panel - New 2/8/19 Download (PDF)
Mylotarg (gemtuzumab ozogamicin) Download (PDF)
N Download (PDF)
Naglazyme (galsulfase) Download (PDF)
Neulasta® (pegfilgrastim) Download (PDF)
Neuropsychological Testing Download (PDF)
Neurotoxins (Botox®, Dysport®, Myobloc® and Xeomin®) Download (PDF)
Neupogen® (filgrastim)  Download (PDF)
Non-invasive H pylori Testing Download (PDF)
Noncoronary Vascular Stents Download (PDF)
Nplate (romiplostim) Download (PDF)
Nucala® (mepolizumab) Download (PDF)
Nuchal Translucency Screening for Down Syndrome Download (PDF)
Nutritional Counseling Services Download (PDF)
O Download (PDF)
Obstructive Sleep Apnea Diagnosis and Treatment - Revised 2/8/19 Download (PDF)
Ocrevus™ (ocrelizumab) Download (PDF)
Off-Label Use of FDA-Approved Drugs and Biologicals Download (PDF)
Onpattro (patisiran) - New 1/1/19 Download (PDF)
Opdivo® (nivolumab) Download (PDF)
Orencia (abatacept) Download (PDF)
Orthognathic Surgery Download (PDF)
Orthopedic Footwear Download (PDF)
Osteochondral Grafting Download (PDF)
Osteogenesis Stimulators Download (PDF)
Otoacoustic Emission Testing for Pediatric Populations in the Primary Care Setting Download (PDF)
Outpatient Cardiac Rehabilitation Download (PDF)
P Download (PDF)
Pain Management Download (PDF)
Pancreatic Islet Cell Transplantation for Chronic Pancreatitis Download (PDF)
Pasireotide (Signifor® LAR) Download (PDF)
Pasteurized Donor Human Breast Milk (PDHM) Download (PDF)
Peripheral Nerve Blocks Download (PDF)
Periurethral Bulking Agents for Urinary Incontinence Download (PDF)
Perjeta (pertuzumab) Download (PDF)
Phototherapy, Photochemotherapy and Photodynamic Therapy for Dermatologic Conditions Download (PDF)
Posterior Tibial Nerve Stimulation for Voiding Dysfunction Download (PDF)
Poteligeo (mogamulizumab-kpkc) - New 1/1/19 Download (PDF)
Prolia®/Xgeva® (denosumab) Download (PDF)
Prostatic Urethral Lift (PUL) Download (PDF)
PROVENGE® (sipuleucel-T) Download (PDF)
Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions Download (PDF)
R Download (PDF)
Radicava (Edaravone) - New 1/1/19 Download (PDF)
Radiofrequency Ablation for Spinal Pain Download (PDF)
Radiofrequency Ablation for Tumors Download (PDF)
Recurrent Pregnancy Loss Download (PDF)
Relizorb (immobilized lipase) Cartridge Download (PDF)
Rhinoplasty Download (PDF)
Risk-Reduction Mastectomy Download (PDF)
Rituxan® (rituximab) Download (PDF)
Rituxan Hycela (rituximab and hyaluronidase Human) - New 1/1/19 Download (PDF)
Ruconest (C1 esterase inhibitor [recombinant]) Download (PDF)
S Download (PDF)
Sacroiliac Joint Fusion Download (PDF)
Sandostatin® LAR (octreotide) Download (PDF)
Selective Internal Radiation Therapy Download (PDF)
Septoplasty Download (PDF)
Simponi Aria (golimumab) Download (PDF)
Soliris® (eculizumab) Download (PDF)
Specialty Outpatient Day-Hospital Services Download (PDF)
Speech-Language Pathology - Interventional Services for Autism Spectrum Disorders Download (PDF)
Spinraza™ (Nusinersen) Download (PDF)
Stelara® (ustekinumab) Download (PDF)
Stereotactic Radiosurgery and Proton Beam Therapy Download (PDF)
Subcutaneous immune globulins (SCIG): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia, Cuvitru Download (PDF)
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Download (PDF)
Surgical Correction of Chest Wall Deformities Download (PDF)
Synagis® (Palivizumab) Download (PDF)
T Download (PDF)
Therapeutic Shoes for Diabetics Download (PDF)
Topical Oxygen Wound Therapy (Medicaid/FHP) Download (PDF)
Total Ankle Replacement Download (PDF)
Transcatheter Aortic Valve Replacement Download (PDF)
Transcranial Magnetic Stimulation for Major Depressive Disorder Download (PDF)
Transurethral Radiofrequency Micro-Remodeling for Female Stress Urinary Incontinence Download (PDF)
Tremfya (guselkumab) - New 1/1/19 Download (PDF)
Trogarzo (Ibalizumab-uiyk) Download (PDF)
Tysabri (natalizumab) Download (PDF)
U Download (PDF)
Unituxin™ (dinutuximab) Download (PDF)
Urine Drug/Alcohol Testing- Revised 2/8/19 Download (PDF)
V Download (PDF)
Vacuum-Assisted Wound Closure Download (PDF)
Vagus Nerve Stimulation for Epilepsy - Revised 12/14/18 Download (PDF)
Vantas® (histrelin acetate) Download (PDF)
Varicose Vein Treatment Download (PDF)
Varubi (rolapitant) Intravenous Download (PDF)
Vectibix® (panitumumab) Download (PDF)
Velcade (bortezomib) - New 1/1/19 Download (PDF)
Vertical Expandable Prosthetic Titanium Rib (VEPTR) Download (PDF)
Virtual Colonoscopy (CT colonography) Download (PDF)
Visual Electrophysiology Testing Download (PDF)
Visual Evoked Potential Testing for Pediatric Populations in the Primary Care Setting Download (PDF)
Vitamin D Deficiency Testing Download (PDF)
Vpriv (velaglucerase alfa) Download (PDF)
Vyxeos™ (daunorubicin and cytarabine) Download (PDF)
W Download (PDF)
Wigs — Medicaid/EPO Direct Pay (Bronze, Silver, Gold, Platinum), Essential Plans Download (PDF)
X Download (PDF)
Xiaflex (collagenase clostridium histolyticum) Download (PDF)
Xofigo for Castration-Resistant Prostate Cancer Download (PDF)
Xolair® (omalizumab) Download (PDF)
Y Download (PDF)
Yervoy™ (ipilimumab) Download (PDF)
Yescarta (axicabtagene ciloleucel) Download (PDF)
Z Download (PDF)
Zilretta (triamcinolone acetonide extended release injection) Download (PDF)
Zoledronic acid (Zometa®, Reclast®) Download (PDF)