Medical Policies

Medical Policies are listed in alphabetical order


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Abraxane® (paclitaxel protein-bound particles)
Actemra (tocilizumab)
Acupuncture — Medicare Dual-Eligible Members
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
Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds
Arthroscopy for the Osteoarthritic knee
Artificial Intervertebral Discs
Assisted Reproductive Technologies - Revised 4/13/18
Autologous Chondrocyte Implantation
Automatic External Defibrillators
Avastin® (bevacizumab) (Intravenous)
Azacitidine (Vidaza®)
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Balloon Sinuplasty
Bariatric Surgery
Bavencio® (avelumab)
BCR-ABL1 Genetic Mutation Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia
Benlysta (belimumab)
Berinert (C1 Esterase Inhibitor Human)
Biomagnetic Therapy
Blinatumomab (Blincyto™)
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)
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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 4/13/18
Cerezyme (imiglucerase)
Chelation Therapy Revised: 3/9/18
Chemical Peels
Chromosomal Microarray Analysis (CMA)
Cimzia® (certolizumab pegol)
Cinryze (C1 Esterase Inhibitor Human)
Clotting Disorder Therapy
Cognitive Rehabilitation Revised: 3/9/18
Continuous Passive Motion Devices
Cortical Stimulation for Epilepsy (NeuroPace®)
Cosmetic Surgery Procedures
Cranial Helmets for Plagiocephaly and Prevention of Head Injury
Cryosurgery for Liver Tumors 
Cryosurgical and Radiofrequency Ablation for Renal Tumors 
Cryosurgical Ablation for Prostate Cancer
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Deep Brain Stimulation
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)
Erythropoiesis Stimulating Agents (ESAs): Epogen/Procrit®
Eteplirsen (Exondys 51™) 
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
Firazyr (icatibant)
Functional Endoscopic Sinus Surgery (FESS)
Fusilev (levoleucovorin)
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Gastric Electrical Stimulation
Gender Reassignment Surgery
Gene Expression Profile Testing for Multiple Myeloma
Gene Expression Profiling - Revised 5/11/18
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
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 Revised: 3/9/18
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
Hyperthermia Treatment for Cancer
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Idiopathic Environmental Intolerance (IEI)
Ilizarov Technique
Imfinzi™ (durvalumab) Revised: 3/9/18
Implantable Cardioverter Defibrillators
Infertility Services
Infliximab Injectable (Inflectra®, Remicade®, Renflexis™)
Insulin Delivery Devices and Continuous Glucose Monitoring Systems - Revised: 5/8/18
Intensive Behavioral Therapy for Obesity
Interspinous Distraction Devices
Intrastromal Corneal Ring Segments for Keratoconus
Intrathecal Baclofen for CNS Spasticity
Intravenous Immune Globulins (immune globulin)
Intravitreal Injections/Implants
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Janus Kinase 2 (JAK2) V617F Gene Mutation Assay
Jevtana (cabazitaxel)
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Kadcyla® (ado-trastuzumab emtansine)
Kalbitor (ecallantide)
Keytruda® (pembrolizumab)
Kymriah™ (tisagenlecleucel) - Revised: 5/1/18
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Lemtrada® (alemtuzumab)
Leukine® (sargramostim)
Level of Care (LOC) -- Ambulatory Surgical Procedures
Lipoprotein Subclassification Testing for Screening, Evaluation and Monitoring of Cardiovascular Disease
Lumbar Fusion and Intervertebral Fusion Devices
Lumizyme (alglucosidase alfa)
Lung Volume Reduction Surgery
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 4/13/18
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Naglazyme (galsulfase)
Neulasta® (pegfilgrastim)
Neuropsychological Testing
Neurotoxins (Botox®, Dysport®, Myobloc® and Xeomin®)
Neupogen® (filgrastim) 
Non-invasive H pylori Testing
Non-invasive Prenatal Testing (NIPT) for Fetal Aneuploidy
Noncoronary Vascular Stents
Nplate (romiplostim)
Nucala® (mepolizumab)
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
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)
Pasteurized Donor Human Breast Milk (PDHM) - Revised: 4/12/18
Peripheral Nerve Blocks
Periurethral Bulking Agents for Urinary Incontinence
Perjeta (pertuzumab)
Phototherapy, Photochemotherapy and Photodynamic Therapy for Dermatologic Conditions
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
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 Barrett’s Esophagus
Radiofrequency Ablation for Spinal Pain
Radiofrequency Ablation for Tumors 
Recurrent Pregnancy Loss
Risk-Reduction Mastectomy
Rituxan® (rituximab)
Ruconest (C1 esterase inhibitor [recombinant])
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Sacroiliac Joint Fusion Revised: 3/9/18
Sandostatin® LAR (octreotide)
Selective Dorsal Rhizotomy for Cerebral Palsy
Selective Internal Radiation Therapy
Simponi Aria (golimumab)
Soliris® (eculizumab)
Specialty Outpatient Day-Hospital Services
Speech-Language Pathology - Interventional Services for Autism Spectrum Disorders
Spinraza™ (Nusinersen)
Stelara® (ustekinumab)
Stereotactic Radiosurgery and Proton Beam Therapy
Subcutaneous immune globulins (SCIG): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia, Cuvitru 
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) - New: 3/9/18
Surgical Correction of Chest Wall Deformities
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)
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Urine Drug/Alcohol Testing - HMO
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Vacuum-Assisted Wound Closure
Vagus Nerve Stimulation for Epilepsy
Vantas® (histrelin acetate)
Varicose Vein Treatment Revised: 3/9/18
Vectibix® (panitumumab)
Vertical Expandable Prosthetic Titanium Rib (VEPTR)
Virtual Colonoscopy (CT colonography)
Visual Electrophysiology Testing
Visual Evoked Potential Testing for Pediatric Populations in the Primary Care Setting
Vitamin D Deficiency Testing Revised: 3/9/18
Vpriv (velaglucerase alfa)
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Wigs — MEDICAID/FHP/EPO Direct Pay (Bronze, Silver, Gold, Platinum)
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Xiaflex collagenase clostridium histolyticum)
Xofigo for Castration-Resistant Prostate Cancer
Xolair® (omalizumab)
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Yervoy™ (ipilimumab)
Yescarta (axicabtagene ciloleucel) - New 4/1/18
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Zoledronic acid (Zometa®, Reclast®)