Welcome to the EmblemHealth Medical Policies page. Members follow the Medical Policies for the company underwriting or administering their benefit plan.
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| 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) |
| Amniotic Membrane Transplantation for Ocular Reconstruction | 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 (PD]F) |
| Cryosurgery for Liver Tumors | 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) |
|---|---|
| EEG - Ambulatory Monitoring Electroencephalogram | Download (PDF) |
| EEG - Noninvasive Electroencephalogram - COMMERCIAL/MEDICAID | 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 | Download (PDF) |
| Gene Expression Profiling and Biomarker Testing for Breast Cancer | Download (PDF) |
| Genetic Analysis of PIK3CA Status in Tumor Cells | Download (PDF) |
| Genetic Counseling and Testing | Download (PDF) |
| Genetic Testing for Colorectal Cancer / Lynch Syndrome | Download (PDF) |
| Genetic Testing for PTEN Hamartoma Tumor 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) |
| Intrastromal Corneal Ring Segments for Keratoconus | 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 - Revised: 4/8/2022 | 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) |
| Noncoronary Vascular Stents | 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 3/11/2022 | 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) |
| Outpatient Cardiac Rehabilitation | 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) |
| Prostatic Urethral Lift (PUL) |
Download (PDF) |
| Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions | Download (PDF) |
| R back to top | Download (PDF) |
|---|---|
| Radiofrequency Ablation for Spinal Pain - Revised 4/18/2022 | Download (PDF) |
| Radiofrequency Ablation of Tumors | Download (PDF) |
| Recurrent Pregnancy Loss - Revised 3/11/2022 | 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) |
| Site of Service Utilization | 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) |
| Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) | Download (PDF) |
| Surgical Correction of Chest Wall Deformities | Download (PDF) |
| Tback to top | Download (PDF) |
|---|---|
| Telehealth — Commercial/Medicaid | Download (PDF) |
| Therapeutic Shoes for Diabetics | Download (PDF) |
| Topical Oxygen Wound Therapy (Medicaid/FHP) | Download (PDF) |
| Total Ankle Replacement | Download (PDF) |
| Transcatheter Aortic Valve Replacement | Download (PDF) |
| Transurethral Radiofrequency Micro-Remodeling for Female Stress Urinary Incontinence | 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) |
| Visual Electrophysiology Testing | Download (PDF) |
| Vitamin D Deficiency Testing | Download (PDF) |
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