Medical Policies | EmblemHealth

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Medical Policies

Welcome to the EmblemHealth Medical Policies page. Members follow the Medical Policies for the company underwriting or administering their benefit plan.


For other Medical Policies, see:

Also see our Medical Technologies Database.



A back to top Download (PDF)
Abdominoplasty/Panniculectomy  Download (PDF)
Acupuncture - EmblemHealth Medicare HMO Plans with Acupuncture Benefit Download (PDF)
Acupuncture for Chronic Lower Back Pain - Medicare Download (PDF)
Analysis of KRAS Status Download (PDF)
Anesthesia for Dental Procedures and Oral and Maxillofacial Surgery — New York Download (PDF)
Application of Bioengineered Skin Substitutes Download (PDF)
Artificial Intervertebral Discs Download (PDF)
Autologous Chondrocyte Implantation Download (PDF)
Automatic Blood Pressure Monitor Download (PDF)
Automatic External Defibrillators Download (PDF)
B back to top Download (PDF)
Balloon Sinuplasty Download (PDF)
Bariatric Surgery Download (PDF)
Biomagnetic Therapy Download (PDF)
Blepharoplasty 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)
C back to top Download (PDF)
Capsule Endoscopy (camera pill) Download (PDF)
Cardiac Event Monitors Download (PDF)
Carrier Screening for Parents or Prospective Parents Download (PDF)
Chemical Peels Download (PDF)
Clinical Trials/Experimental/Investigational Procedure/Treatments/Rare Disease Treatment — Commercial and Medicaid Download (PDF)
Clinical Trials — Medicare Download (PDF)
Continuous Passive Motion Devices Download (PDF)
Cortical Stimulation for Epilepsy (NeuroPace®) Download (PDF)
Cosmetic and Reconstructive Surgery Procedures Download (PDF)
Cryosurgical and Radiofrequency Ablation for Renal Tumors  Download (PDF)
Cryosurgical Ablation for Prostate Cancer Download (PDF)
D back to top Download (PDF)
Dental Care or Treatment Necessary Due to Congenital Disease or Anomaly — New York Download (PDF)
Dental Trauma Guidelines for Medical Plan Download (PDF)
Dermabrasion Download (PDF)
Dorsal Column Stimulator for Pain Management Download (PDF)
Doula Services - Medicaid Download (PDF)
E back to top Download (PDF)
External Breast Prosthesis/Bra Download (PDF)
F back to top Download (PDF)
Fecal Incontinence Treatment Download (PDF)
Fecal microbiota transplant (FMT) for Recurrent Clostridium  difficile Infection Download (PDF)
G back to top Download (PDF)
gammaCore Sapphire CV for the Coronavirus Disease 2019 (COVID-19)  Download (PDF)
Gastric Electrical Stimulation Download (PDF)
Gender Affirming/Reassignment Surgery — New York Download (PDF)
Gene Expression Profile Testing for Multiple Myeloma Download (PDF)
Gene Expression Profiling - Revised 10/14/2022 Download (PDF)
Gene Expression Profiling and Biomarker Testing for Breast Cancer Download (PDF)
Genetic Testing for Colorectal Cancer / Lynch Syndrome Download (PDF)
Glaucoma Surgery Download (PDF)
H back to top Download (PDF)
High Frequency Chest Wall Oscillation Devices and Intrapulmonary Percussive Ventilators  Download (PDF)
Home Birth Midwifery Services Download (PDF)
Home Infusion Therapy—Registered Nurse Download (PDF)
Home Uterine Activity Monitoring Download (PDF)
Hyperbaric Oxygen Therapy Download (PDF)
Hyperthermia Treatment for Cancer Download (PDF)
I back to top Download (PDF)
Idiopathic Environmental Intolerance (IEI) Download (PDF)
Implantable Cardioverter Defibrillators Download (PDF)
Infertility Services – Commercial Download (PDF)
Insulin Delivery Devices and Continuous Glucose Monitoring Systems Download (PDF)
Interspinous Distraction Devices Download (PDF)
Intraoperative Radiation Therapy for Breast Cancer Download (PDF)
L back to top Download (PDF)
Lipoprotein Subclassification Testing for Screening, Evaluation and Monitoring of Cardiovascular Disease Download (PDF)
Lumbar Fusion and Intervertebral Fusion Devices Download (PDF)
Lyme Disease Diagnosis and Treatment Download (PDF)
Lymphedema Treatment Download (PDF)
M back to top Download (PDF)
Mechanical Stretching Devices Download (PDF)
Medical Necessity Guidelines: Experimental, Investigational or Unproven Services Download (PDF)
MYvantage® Hereditary Comprehensive Cancer Panel Download (PDF)
N back to top Download (PDF)
Neuropsychological Testing Download (PDF)
Noninvasive H pylori Testing Download (PDF)
Noninvasive Prenatal Testing (NIPT) for Fetal Aneuploidy Download (PDF)
Nuchal Translucency Screening for Down Syndrome Download (PDF)
Nutritional Counseling Services Download (PDF)
O back to top Download (PDF)
Obstructive Sleep Apnea Diagnosis and Treatment - Revised 9/9/2022 Download (PDF)
Ocular Photoscreening Download (PDF)
Orthognathic Surgery Download (PDF)
Orthopedic Footwear Download (PDF)
Osteochondral Grafting Download (PDF)
Osteogenesis Stimulators Download (PDF)
Otoacoustic Emission Testing Download (PDF)
P back to top Download (PDF)
Pain Management  Download (PDF)
Pancreatic Islet Cell Transplantation for Chronic Pancreatitis Download (PDF)
Pasteurized Donor Human Breast Milk (PDHM) Download (PDF)
Penile Implants Download (PDF)
Peripheral Nerve Blocks Download (PDF)
Periurethral Bulking Agents for Urinary Incontinence Download (PDF)
Phototherapy, Photochemotherapy and Photodynamic Therapy for Dermatologic Conditions  Download (PDF)
Posterior Tibial Nerve Stimulation for Voiding Dysfunction Download (PDF)
Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions Download (PDF)
R back to top Download (PDF)
Radiofrequency Ablation for Spinal Pain Download (PDF)
Radiofrequency Ablation of Tumors Download (PDF)
Recurrent Pregnancy Loss Download (PDF)
Rhinoplasty Download (PDF)
S back to top Download (PDF)
Sacroiliac Joint Fusion Download (PDF)
Selective Internal Radiation Therapy Download (PDF)
Septoplasty Download (PDF)
Specialty Outpatient Day-Hospital Services Download (PDF)
Speech-Language Pathology - Interventional Services for Autism Spectrum Disorders Download (PDF)
Stereotactic Radiosurgery and Proton Beam Therapy Download (PDF)
Surgical Correction of Chest Wall Deformities Download (PDF)
Tback to top Download (PDF)
Topical Oxygen Wound Therapy (Medicaid/FHP) Download (PDF)
Transcatheter Aortic Valve Replacement Download (PDF)
V back to top Download (PDF)
Vacuum-Assisted Wound Closure Download (PDF)
Varicose Vein Treatment Download (PDF)
Vertical Expandable Prosthetic Titanium Rib (VEPTR) Download (PDF)
Virtual Colonoscopy (CT colonography) Download (PDF)
Vitamin D Deficiency Testing Download (PDF)