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|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
(Does Not Apply to ConnectiCare)		 Download (PDF)
Analysis of KRAS Status Download (PDF)
Anesthesia for Dental Procedures and Oral and Maxillofacial Surgery — New York
(Does Not Apply to ConnectiCare)		 Download (PDF)
Application of Bioengineered Skin Substitutes
(Does Not Apply to ConnectiCare)		 Download (PDF)
Artificial Intervertebral Discs
(Does Not Apply to ConnectiCare)		 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
(Does Not Apply to ConnectiCare)		 Download (PDF)
Dental Trauma Guidelines for Medical Plan Download (PDF)
Dermabrasion Download (PDF)
Dorsal Column Stimulator for Pain Management
(Does Not Apply to ConnectiCare)		 Download (PDF)
E back to top Download (PDF)
External Breast Prosthesis/Bra
(Does Not Apply to ConnectiCare)		 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
(Does Not Apply to ConnectiCare)		 Download (PDF)
Home Birth Midwifery Services Download (PDF)
Home Uterine Activity Monitoring Download (PDF)
Hyperbaric Oxygen Therapy Download (PDF)
I back to top Download (PDF)
Implantable Cardioverter Defibrillators Download (PDF)
Infertility Services – Commercial
(Does Not Apply to ConnectiCare)		 Download (PDF)
Insulin Delivery Devices and Continuous Glucose Monitoring Systems Download (PDF)
Interspinous Distraction Devices
(Does Not Apply to ConnectiCare)		 Download (PDF)
Intraoperative Radiation Therapy for Breast Cancer
(Does Not Apply to ConnectiCare)		 Download (PDF)
L back to top Download (PDF)
Lumbar Fusion and Intervertebral Fusion Devices
(Does Not Apply to ConnectiCare)		 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)
O back to top Download (PDF)
Obstructive Sleep Apnea Diagnosis and Treatment Download (PDF)
Ocular Photoscreening Download (PDF)
Orthognathic Surgery Download (PDF)
Orthopedic Footwear
(Does Not Apply to ConnectiCare)		 Download (PDF)
Osteogenesis Stimulators
(Does Not Apply to ConnectiCare)		 Download (PDF)
Osteochondral Grafting Download (PDF)
Otoacoustic Emission Testing Download (PDF)
P back to top Download (PDF)
Pain Management
(Does Not Apply to ConnectiCare)		 Download (PDF)
Pancreatic Islet Cell Transplantation for Chronic Pancreatitis
(Does Not Apply to ConnectiCare)		 Download (PDF)
Pasteurized Donor Human Breast Milk (PDHM)
(Does Not Apply to ConnectiCare)		 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
(Does Not Apply to ConnectiCare)		 Download (PDF)
Rhinoplasty Download (PDF)
S back to top Download (PDF)
Sacroiliac Joint Fusion
(Does Not Apply to ConnectiCare)		 Download (PDF)
Selective Internal Radiation Therapy
(Does Not Apply to ConnectiCare)		 Download (PDF)
Septoplasty Download (PDF)
Site of Service Utilization Download (PDF)
Speech-Language Pathology - Interventional Services for Autism Spectrum Disorders
(Does Not Apply to ConnectiCare)		 Download (PDF)
Stereotactic Radiosurgery and Proton Beam Therapy
(Does Not Apply to ConnectiCare)		 Download (PDF)
Surgical Correction of Chest Wall Deformities Download (PDF)
Tback to top Download (PDF)
Topical Oxygen Wound Therapy (Medicaid/FHP)
(Does Not Apply to ConnectiCare)		 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)