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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:

Behavioral Health
ConnectiCare’s Medical Policies
EmblemHealth Plan, Inc.
- Radiology/Cardiology
- Radiation Oncology
EmblemHealth Spine Surgery and Pain Management Therapies Program
Enterprise Pharmacy Medical Policies
Healthplex Dental Policies
Health Insurance Plan of Greater New York (HIP)/EmblemHealth Insurance Company
MCG
New Century Health – Medical Oncology Policies

Also see our Medical Technologies Database.

A|B|C|D|E|F|G|H|I|J|K|L|M|N|O|P|Q|R|S|T|U|V|W|Y|Z
A back to top	Download (PDF)
Abdominoplasty/Panniculectomy	Download (PDF)
Acupuncture - EmblemHealth Medicare HMO Plans with Acupuncture Benefit	Download (PDF)
Acupuncture for Chronic Low Back Pain	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 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)
BRAF Mutation Analysis	Download (PDF)
Breast Implants and Reconstruction	Download (PDF)
Breast Reduction Mammoplasty	Download (PDF )

C back to top	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)
Cochlear and Other Auditory Implants	Download (PDF)
Continuous Passive Motion Devices	Download (PDF)
Cortical Stimulation for Epilepsy (NeuroPace®)	Download (PDF)
Cosmetic and Reconstructive Surgery Procedures	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 (P DF)
Dermabrasion	Download (PDF)
Dorsal Column Stimulator for Pain Management	Download (P DF)

E back to top	Download (PDF)
External Breast Prosthesis/Bra	Download (PDF)

F back to top	Download (PDF)
Fecal Incontinence Treatment	Download (PDF)
Fetal Surgery	Download (PDF)

G back to top	Download (PDF)
Gastric Electrical Stimulation	Download (PDF)
Gender Affirming Surgery	Download (PDF)
Gene Expression Profiling	Download (PDF)
Gene Expression Profiling and Biomarker Testing for Breast Cancer	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 Infusion Therapy—Registered Nurse	Download (PDF)
Home Birth Midwifery Services	Download (PDF)
Home Uterine Activity Monitoring	Download (PDF)
Hyperbaric Oxygen Therapy	Downloa d (PDF)

I back to top	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)
Lumbar Fusion and Intervertebral Fusion Devices	Download (PDF)
Lyme Disease Intravenous Treatment	Download (PDF)

M back to top	Download (PDF)
Mechanical Stretching Devices	Download (PDF)
Medical Necessity Guidelines: Experimental, Investigational or Unproven Services	Download (PDF)

N back to top	Download (PDF)
Neuropsychological Testing	Download (PDF)
Non-Emergent Ambulance Services	Download (PDF)
Non-Invasive Helicobacter Pylori Testing	Download (PDF)

O back to top	Download (PDF)
Obstructive Sleep Apnea Diagnosis and Treatment	Download (PDF)
Ocular Photoscreening	Download (PDF)
Orthognathic Surgery	Download (PDF)
Orthopedic Footwear	Download (PDF)
Osteogenesis Stimulators	Download (PDF)
Osteochondral Grafting	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)
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)
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)

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