Medical Policies

Medical Policies are listed in alphabetical order


A Download (PDF)
Abdominoplasty/Panniculectomy Download (PDF)
Abraxane® (paclitaxel protein-bound particles) Download (PDF)
Actemra (tocilizumab) Download (PDF)
Acupuncture — Medicare Dual-Eligible Members Download (PDF)
Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy Download (PDF)
Aldurazyme (laronidase) Download (PDF)
Alimta® (pemetrexed) Download (PDF)
AlloMap® Molecular Expression Testing for Post-Heart-Transplant Rejection 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)
Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds Download (PDF)
Arthroscopy for the Osteoarthritic knee Download (PDF)
Artificial Intervertebral Discs Download (PDF)
Assisted Reproductive Technologies Download (PDF)
Autologous Chondrocyte Implantation Download (PDF)
Automatic External Defibrillators Download (PDF)
Avastin® (bevacizumab) (Intravenous) Download (PDF)
Azacitidine (Vidaza®) Download (PDF)

B Download (PDF)
Balloon Sinuplasty Download (PDF)
Bariatric Surgery - Revised 6/8/18 Download (PDF)
Bavencio® (avelumab) Download (PDF)
BCR-ABL1 Genetic Mutation Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia Download (PDF)
Benlysta (belimumab) Download (PDF)
Berinert (C1 Esterase Inhibitor Human) Download (PDF)
Biomagnetic Therapy Download (PDF)
Blepharoplasty 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)
Cardiac Ion Channel Genetic Testing Download (PDF)
Cardiac Resynchronization Therapy (Biventricular Pacing) 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)
Clotting Disorder Therapy Download (PDF)
Cognitive Rehabilitation Download (PDF)
Continuous Passive Motion Devices Download (PDF)
Cortical Stimulation for Epilepsy (NeuroPace®) Download (PDF)
Cosmetic Surgery Procedures Download (PDF)
Cranial Helmets for Plagiocephaly 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)
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)
Epidermal Growth Factor Receptor Mutation Analysis for Patients with Non-Small-Cell Lung Cancer Download (PDF)
Erbitux® (cetuximab) Download (PDF)
Erythropoiesis Stimulating Agents (ESAs): Aranesp® (darbepoetin alfa) Download (PDF)
Erythropoiesis Stimulating Agents (ESAs): Epogen/Procrit® Download (PDF)
Eteplirsen (Exondys 51™) Download (PDF)
External Breast Prosthesis /Bra Download (PDF)
External Counterpulsation Download (PDF)
F Download (PDF)
Fabrazyme (agalsidase beta) Download (PDF)
Fasenra™ (benralizumab) - New: 5/1/18 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 - Revised 6/8/18 Download (PDF)
Gene Expression Profile Testing for Multiple Myeloma Download (PDF)
Gene Expression Profiling - Revised 5/11/18 Download (PDF)
Gene Expression Profiling and Biomarker Testing for Breast Cancer Download (PDF)
Gene Expression Profiling of Melanomas 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 Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome Download (PDF)
Genetic Testing for Colorectal Cancer / Lynch Syndrome Download (PDF)
Genetic Testing for Cystic Fibrosis Download (PDF)
Genetic Testing for Factor V Leiden Mutation Analysis Download (PDF)
Genetic Testing for Frontotemporal Dementia (FTD) Download (PDF)
Genetic Testing for Hereditary Cardiomyopathy Download (PDF)
Genetic Testing for Hereditary Hemochromatosis Download (PDF)
Genetic Testing for Hereditary Pancreatitis Download (PDF)
Genetic Testing for Inherited Peripheral Neuropathies Download (PDF)
Genetic Testing for PTEN Hamartoma Tumor Syndrome Download (PDF)
Genetic Testing for RET Proto-Oncogene Germline Point Mutation Download (PDF)
Genetic Testing for Statin-Induced Myopathy Download (PDF)
Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome) Download (PDF)
Glaucoma Surgery Download (PDF)
Gynecomastia Surgery 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 - Revised: 6/8/18 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)
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  - Revised: 5/8/18 Download (PDF)
Intensive Behavioral Therapy for Obesity Download (PDF)
Interspinous Distraction Devices - Revised: 6/8/18 Download (PDF)
Intrastromal Corneal Ring Segments for Keratoconus Download (PDF)
Intrathecal Baclofen for CNS Spasticity Download (PDF)
Intravenous Immune Globulins (immune globulin) Download (PDF)
Intravitreal Injections/Implants Download (PDF)
J Download (PDF)
Janus Kinase 2 (JAK2) V617F Gene Mutation Assay Download (PDF)
Jevtana (cabazitaxel) Download (PDF)
K Download (PDF)
Kadcyla® (ado-trastuzumab emtansine) Download (PDF)
Kalbitor (ecallantide) Download (PDF)
Keytruda® (pembrolizumab) Download (PDF)
Kymriah™ (tisagenlecleucel)  - Revised: 7/13/18 Download (PDF)
L Download (PDF)
Lemtrada® (alemtuzumab) Download (PDF)
Leukine® (sargramostim) Download (PDF)
Level of Care (LOC) -- Ambulatory Surgical Procedures 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) - New 7/25/18 Download (PDF)
Luxturna™ (Voretigene neparvovec) — Medicaid - New 6/1/18 Download (PDF)
Lyme Disease Diagnosis and Treatment  Download (PDF)
Lymphedema Treatment Download (PDF)
M Download (PDF)
Magnetoencephalography-Magnetic Source Imaging Download (PDF)
Mechanical Stretching Devices Download (PDF)
Medical Necessity Guidelines for Non-Covered Investigational Services Download (PDF)
Metal on Metal Hip Resurfacing Download (PDF)
Metoclopramide and Ondansetron Infusion for Hyperemesis Gravidarum 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)
Non-invasive Prenatal Testing (NIPT) for Fetal Aneuploidy 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)
Obstetric Ultrasonography Download (PDF)
Obstructive Sleep Apnea Diagnosis and Treatment Download (PDF)
Ocrevus™ (ocrelizumab) Download (PDF)
Off-Label Use of FDA-Approved Drugs and Biologicals Download (PDF)
Opdivo® (nivolumab) Download (PDF)
Orencia (abatacept) Download (PDF)
Orthognathic Surgery Download (PDF)
Orthopedic Footwear Download (PDF)
Osteochondral Grafting Download (PDF)
Osteogenesis Stimulators - Revised: 6/8/18 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)
Prolia®/Xgeva® (denosumab) Download (PDF)
Prostatic Urethral Lift (PUL) — MEDICARE Download (PDF)
PROVENGE® (sipuleucel-T) Download (PDF)
Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions Download (PDF)
R Download (PDF)
Radiofrequency Ablation for Barrett’s Esophagus Download (PDF)
Radiofrequency Ablation for Spinal Pain Download (PDF)
Radiofrequency Ablation for Tumors Download (PDF)
Recurrent Pregnancy Loss Download (PDF)
Rhinoplasty Download (PDF)
Risk-Reduction Mastectomy Download (PDF)
Rituxan® (rituximab) 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)
Sympathectomy for Hyperhidrosis Download (PDF)
Synagis® (Palivizumab) Download (PDF)
T Download (PDF)
Therapeutic Shoes for Diabetics Download (PDF)
Tonsillectomy/Adenoidectomy 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)
Tysabri (natalizumab) Download (PDF)
U Download (PDF)
Urine Drug/Alcohol Testing - HMO Download (PDF)
V Download (PDF)
Vacuum-Assisted Wound Closure Download (PDF)
Vagus Nerve Stimulation for Epilepsy Download (PDF)
Vantas® (histrelin acetate) Download (PDF)
Varicose Vein Treatment Download (PDF)
Vectibix® (panitumumab) 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)
W Download (PDF)
Wigs — MEDICAID/FHP/EPO Direct Pay (Bronze, Silver, Gold, Platinum) 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)
Zoledronic acid (Zometa®, Reclast®) Download (PDF)