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

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Abdominoplasty/Panniculectomy
Abraxane® (paclitaxel protein-bound particles)
Actemra (tocilizumab)
Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy
Aldurazyme (laronidase)
Alimta® (pemetrexed)
AlloMap® Molecular Expression Testing for Post-Heart-Transplant Rejection
Aloxi® (palonosetron)
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
Autologous Chondrocyte Implantation  - Revised: 10/13/17
Automatic External Defibrillators
Avastin® (bevacizumab) (Intravenous)
Azacitidine (Vidaza®)
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Balloon Sinuplasty
Bariatric Surgery
Bavencio® (avelumab) - New 10/13/17
BCR-ABL1 Genetic Mutation Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia
Benlysta (belimumab)
Berinert (C1 Esterase Inhibitor Human)
Blepharoplasty
Blinatumomab (Blincyto™)
Biomagnetic Therapy
Bone-Anchored Hearing Aids
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
Brineura (cerliponase alfa) - New 10/13/17
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Campath® (Alemtuzumab)
Canaloplasty and Viscocanalostomy
Capsule Endoscopy (camera pill)
Cardiac Event Monitors
Cardiac Ion Channel Genetic Testing
Cardiac Resynchronization Therapy (Biventricular Pacing)
Carrier Screening for Parents or Prospective Parents - Revised: 10/13/17
Cerezyme (imiglucerase)
Chelation Therapy
Chemical Peels
Chromosomal Microarray Analysis (CMA)
Cimzia® (certolizumab pegol)
Cinryze (C1 Esterase Inhibitor Human)
Clotting Disorder Therapy - Revised: 10/13/17
Cognitive Rehabilitation
Continuous Passive Motion Devices
Cortical Stimulation for Epilepsy (NeuroPace®) - New 10/13/17
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
Dermabrasion
Dorsal Column Stimulator for Pain Management
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Elaprase® (idursulfase)
Elelyso (taliglucerase alfa)
Endoscopic and Percutaneous Lysis of Epidural Adhesions (RACZ Procedure) — MEDICARE ONLY
Entyvio (vedolizumab)
Epidermal Growth Factor Receptor Mutation Analysis for Patients with Non-Small-Cell Lung Cancer
Erbitux® (cetuximab)
Erythropoiesis Stimulating Agents (ESAs): Aranesp® (darbepoetin alfa) - Revised: 7/14/17
Erythropoiesis Stimulating Agents (ESAs): Epogen/Procrit®
Eteplirsen (Exondys 51™) ) - Revised: 9/8/17
External Breast Prosthesis /Bra
External Counterpulsation
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Fabrazyme (agalsidase beta)
Fecal Incontinence Treatment
Fecal microbiota transplant (FMT) for Recurrent Clostridium difficile Infection - Revised 7/14/17
Firazyr (icatibant)
Functional Endoscopic Sinus Surgery (FESS)
Fusilev (levoleucovorin)
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Gastric Electrical Stimulation
Gender Reassignment Surgery - Revised: 8/11/17
Gene Expression Profile Testing for Multiple Myeloma
Gene Expression Profiling
Gene Expression Profiling and Biomarker Testing for Breast Cancer
Gene Expression Profiling of Melanomas
Genetic Analysis of PIK3CA Status in Tumor Cells
Genetic Counseling and Testing - Revised: 10/13/17
Genetic Testing for Alzheimer’s Disease
Genetic Testing for Cancer Susceptibility
Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome
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 Hereditary Cardiomyopathy
Genetic Testing for Hereditary Hemochromatosis
Genetic Testing for Hereditary Pancreatitis
Genetic Testing for Inherited Peripheral Neuropathies
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
Gynecomastia Surgery
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H.P. Acthar® Gel
Halaven™ (eribulin)
Herceptin® (trastuzumab)
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
Hysterectomy
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Idiopathic Environmental Intolerance (IEI)
Ilizarov Technique
Imfinzi™ (durvalumab) - New 10/13/17
Implantable Cardioverter Defibrillators
Infertility Services
Infliximab Injectable (Inflectra®, Remicade®)
Insulin Delivery Devices and Continuous Glucose Monitoring Systems
Intensive Behavioral Therapy for Obesity
Interspinous Distraction Devices
Intrastromal Corneal Ring Segments for Keratoconus
Intravenous Immune Globulins (immune globulin)
Intrathecal Baclofen for CNS Spasticity
Intravitreal Injections/Implants - Revised 7/14/17
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Janus Kinase 2 (JAK2) V617F Gene Mutation Assay
Jevtana (cabazitaxel)
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Kalbitor (ecallantide)
Kadcyla® (ado-trastuzumab emtansine)
Keytruda® (pembrolizumab)
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Lemtrada® (alemtuzumab)
Leukine® (sargramostim)
Lipoprotein Subclassification Testing for Screening, Evaluation and Monitoring of Cardiovascular Disease
Level of Care (LOC) -- Ambulatory Surgical Procedures
Lumbar Fusion and Intervertebral Fusion Devices
Lumizyme (alglucosidase alfa)
Lung Volume Reduction Surgery
Lyme Disease Diagnosis and Treatment  - Revised: 10/13/17
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
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Naglazyme (galsulfase)
Nasal Spray Flu Vaccine
Neulasta® (pegfilgrastim) - Revised: 8/11/17
Neuropsychological Testing
Neurotoxins (Botox®, Dysport®, Myobloc® and Xeomin®)
Neupogen® (filgrastim) - Revised: 8/11/17
Nplate (romiplostim)
Non-invasive H pylori Testing
Non-invasive Prenatal Testing (NIPT) for Fetal Aneuploidy
Noncoronary Vascular Stents
Nucala® (mepolizumab) - New 10/13/17
Nuchal Translucency Screening for Down Syndrome
Nutritional Counseling Services
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Obstetric Ultrasonography
Obstructive Sleep Apnea Diagnosis and Treatment
Ocrevus™ (ocrelizumab)
Off-Label Use of FDA-Approved Drugs and Biologicals
Omalizumab (Xolair®)
Opdivo® (nivolumab)
Orencia (abatacept)
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
Periurethral Bulking Agents for Urinary Incontinence
Perjeta (pertuzumab)
Phototherapy, Photochemotherapy and Photodynamic Therapy for Dermatologic Conditions - Revised: 9/21/17
Posterior Tibial Nerve Stimulation for Voiding Dysfunction - New 7/14/17
Prolia®/Xgeva® (denosumab)
Prostatic Urethral Lift (PUL) — MEDICARE
PROVENGE® (sipuleucel-T)
Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions
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Radiofrequency Ablation for Tumors 
Radiofrequency Ablation for Barrett’s Esophagus
Radiofrequency Ablation for Spinal Pain
Recurrent Pregnancy Loss
Rhinoplasty
Risk-Reduction Mastectomy
Rituxan® (rituximab)
Ruconest (C1 esterase inhibitor [recombinant])
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Sacroiliac Joint Fusion
Sandostatin® LAR (octreotide)
Selective Dorsal Rhizotomy for Cerebral Palsy
Selective Internal Radiation Therapy
Septoplasty
Simponi Aria (golimumab)
Soliris® (eculizumab)
Specialty Outpatient Day-Hospital Services
Speech-Language Pathology - Interventional Services for Autism Spectrum Disorders
Spinraza™ (Nusinersen)
Stelara® (ustekinumab)
Subcutaneous immune globulins (SCIG): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia, Cuvitru 
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
Tonsillectomy/Adenoidectomy
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)
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Urine Drug/Alcohol Testing - HMO- New: 10/16/17
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Vacuum-Assisted Wound Closure
Vagus Nerve Stimulation for Epilepsy
Vantas® (histrelin acetate)
Varicose Vein Treatment
Vectibix® (panitumumab)
Vertical Expandable Prosthetic Titanium Rib (VEPTR)
Virtual Colonoscopy (CT colonography)
Visual Electrophysiology Testing - New 7/14/17
Visual Evoked Potential Testing for Pediatric Populations in the Primary Care Setting
Vitamin D Deficiency Testing
Vpriv (velaglucerase alfa)
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Wigs — MEDICAID/FHP/EPO Direct Pay (Bronze, Silver, Gold, Platinum)
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Xiaflex
Xofigo for Castration-Resistant Prostate Cancer
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Yervoy™ (ipilimumab)
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Zoledronic acid (Zometa®, Reclast®)