Medical Policies
| A | Download (PDF) |
|---|---|
| Abdominoplasty/Panniculectomy | Download (PDF) |
| Abraxane® (paclitaxel protein-bound particles) | Download (PDF) |
| Actemra (tocilizumab) | Download (PDF) |
| Acupuncture - EmblemHealth Medicare HMO Plans with Acupuncture Benefit | Download (PDF) |
| Adcetris (brentuximab vedotin) | Download (PDF) |
| Ajovy (fremanezumab-vfrm) - New 3/1/19 | Download (PDF) |
| Akynzeo (fosnetupitant and palonosetron) Injection | Download (PDF) |
| Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy | Download (PDF) |
| Aldurazyme (laronidase) | Download (PDF) |
| Alimta® (pemetrexed) | Download (PDF) |
| Aliqopa™ (copanlisib) | Download (PDF) |
| Aloxi® (palonosetron) | Download (PDF) |
| Alpha-1-Proteinase Inhibitors Infusion Therapy | 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) |
| Apokyn (apomorphine) | Download (PDF) |
| Application of Bioengineered Skin Substitutes | Download (PDF) |
| Arcalyst (rilonacept) | Download (PDF) |
| Artificial Intervertebral Discs | Download (PDF) |
| Arzerra (ofatumumab) | Download (PDF) |
| Assisted Reproductive Technologies | Download (PDF) |
| Autologous Chondrocyte Implantation | Download (PDF) |
| Automatic Blood Pressure Monitor | Download (PDF) |
| Automatic External Defibrillators | Download (PDF) |
| Avastin® (bevacizumab) (Intravenous) | Download (PDF) |
| Aveed (testosterone undecanoate) | Download (PDF) |
| Azacitidine (Vidaza®) | Download (PDF) |
| Azedra® (Iobenguane I-131) | Download (PDF) |
| B | Download (PDF) |
|---|---|
| Balloon Sinuplasty | Download (PDF) |
| Bariatric Surgery - Revised 7/12/19 | Download (PDF) |
| Bavencio® (avelumab) | Download (PDF) |
| Baxdela (delafloxacin) for Injection | Download (PDF) |
| Bendamustine (Bendeka, Treanda, Belrapzo) | Download (PDF) |
| Benlysta (belimumab) | Download (PDF) |
| Berinert (C1 Esterase Inhibitor Human) | Download (PDF) |
| Besponsa® (inotuzumab ozogamicin) | Download (PDF) |
| Biomagnetic Therapy | Download (PDF) |
| Blepharoplasty | Download (PDF) |
| Blinatumomab (Blincyto™) | Download (PDF) |
| Bone Mineral Density Studies in Adult Populations | Download (PDF) |
| Boniva (ibandronate) | 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) |
| Brineura (cerliponase alfa) | Download (PDF) |
| C | Download (PDF) |
|---|---|
| Cablivi (caplacizumab-yhdp) | Download (PDF) |
| Campath® (Alemtuzumab) | Download (PDF) |
| Canaloplasty and Viscocanalostomy | Download (PDF) |
| Capsule Endoscopy (camera pill) - Revised 7/12/19 | Download (PDF) |
| Cardiac Event Monitors | Download (PDF) |
| Carrier Screening for Parents or Prospective Parents | Download (PDF) |
| Cerezyme (imiglucerase) | Download (PDF) |
| Chemical Peels | Download (PDF) |
| Chromosomal Microarray Analysis (CMA) | Download (PDF) |
| Cimzia® (certolizumab pegol) | Download (PDF) |
| Cinqair (reslizumab) | Download (PDF) |
| Cinryze (C1 Esterase Inhibitor Human) | Download (PDF) |
| Cinvanti (aprepitant) Injectable Emulsion | Download (PDF) |
| Clinical Trials/Experimental/Investigational Procedure/Treatments/Rare Disease Treatment — Commercial and Medicaid | Download (PDF) |
| Clinical Trials — Medicare | Download (PDF) |
| Clolar (clofarabine) | Download (PDF) |
| Clotting Disorder Therapy | Download (PDF) |
| Colony Stimulating Factors: Fulphila™ (pegfilgrastim-jmdb) | Download (PDF) |
| Colony Stimulating Factors: Nivestym™ (filgrastim-aafi) | Download (PDF) |
| Colony Stimulating Factors: Udenyca™ (pegfilgrastim-cbqv) | Download (PDF) |
| Continuous Passive Motion Devices | Download (PDF) |
| Cortical Stimulation for Epilepsy (NeuroPace®) | Download (PDF) |
| Cosmetic Surgery Procedures | Download (PDF) |
| Crysvita (burosumab-twza) | Download (PDF) |
| Cyramza® (ramucirumab) | Download (PDF) |
| Cryosurgery for Liver Tumors | Download (PDF) |
| Cryosurgical and Radiofrequency Ablation for Renal Tumors | Download (PDF) |
| Cryosurgical Ablation for Prostate Cancer | Download (PDF) |
| Cytogam (cytomegalovirus immune globulin, human) | Download (PDF) |
| D | Download (PDF) |
|---|---|
| Dacogen (decitabine) | Download (PDF) |
| Darzalex (daratumumab) | 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 | Download (PDF) |
|---|---|
| Elaprase® (idursulfase) | Download (PDF) |
| Elelyso (taliglucerase alfa) | Download (PDF) |
| Eloxatin (oxaliplatin) | Download (PDF) |
| Elzonris (Tagraxofusp-erzs) - New 7/1/19 | Download (PDF) |
| Empliciti (elotuzumab) | Download (PDF) |
| Endoscopic and Percutaneous Lysis of Epidural Adhesions (RACZ Procedure) — MEDICARE ONLY | Download (PDF) |
| Entyvio (vedolizumab) | Download (PDF) |
| Erbitux® (cetuximab) | Download (PDF) |
| Erythropoiesis Stimulating Agents (ESAs): Aranesp® (darbepoetin alfa) | Download (PDF) |
| Erythropoiesis Stimulating Agents (ESAs): Epogen/Procrit® (epoetin alfa) | Download (PDF) |
| Eteplirsen (Exondys 51™) | Download (PDF) |
| Evenity (romosozumab-aqqg) | Download (PDF) |
| External Breast Prosthesis /Bra | Download (PDF) |
| F | Download (PDF) |
|---|---|
| Fabrazyme (agalsidase beta) | Download (PDF) |
| Fasenra™ (benralizumab) | Download (PDF) |
| Fecal Incontinence Treatment | Download (PDF) |
| Fecal microbiota transplant (FMT) for Recurrent Clostridium difficile Infection | Download (PDF) |
| Firazyr (icatibant) | Download (PDF) |
| Folotyn (pralatrexate) | Download (PDF) |
| Functional Endoscopic Sinus Surgery (FESS) | Download (PDF) |
| Fusilev (levoleucovorin) | Download (PDF) |
| G | Download (PDF) |
|---|---|
| Gamifant (Emapalumab-lzsg) - New 7/1/19 | Download (PDF) |
| Gastric Electrical Stimulation | Download (PDF) |
| Gazyva (obinutuzumab) | 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 Alzheimer’s Disease | Download (PDF) |
| Genetic Testing for Colorectal Cancer / Lynch Syndrome | Download (PDF) |
| Genetic Testing for Frontotemporal Dementia (FTD) | Download (PDF) |
| Genetic Testing for Hereditary Cardiomyopathy | Download (PDF) |
| Genetic Testing for Hereditary Pancreatitis | Download (PDF) |
| Genetic Testing for PTEN Hamartoma Tumor Syndrome | Download (PDF) |
| Genetic Testing for Statin-Induced Myopathy | Download (PDF) |
| Glaucoma Surgery | Download (PDF) |
| H | Download (PDF) |
|---|---|
| H.P. Acthar® Gel | Download (PDF) |
| Halaven™ (eribulin) | Download (PDF) |
| Hepagam B (hepatitis B immune globulin) | Download (PDF) |
| High Frequency Chest Wall Oscillation Devices and Intrapulmonary Percussive Ventilators | Download (PDF) |
| Home Birth Midwifery Services | Download (PDF) |
| Home Pulse Oximetry for Infants and Children | Download (PDF) |
| Home Uterine Activity Monitoring | Download (PDF) |
| Hyaluronate Injections for Osteoarthritis of the Knee — COMMERICAL and MEDICARE | Download (PDF) |
| Hydroxyprogesterone Caproate (Makena®) for the Prevention of Preterm Labor | Download (PDF) |
| Hyperbaric Oxygen Therapy | Download (PDF) |
| Hyperthermia Treatment for Cancer | Download (PDF) |
| I | Download (PDF) |
|---|---|
| Idiopathic Environmental Intolerance (IEI) | Download (PDF) |
| Ilaris (canakinumab) | Download (PDF) |
| Ilizarov Technique | Download (PDF) |
| Ilumya (tildrakizumab-asmn) | Download (PDF) |
| Imfinzi™ (durvalumab) | Download (PDF) |
| Imlygic (Talimogene laherparepvec) | Download (PDF) |
| Implantable Cardioverter Defibrillators | Download (PDF) |
| Infertility Services | Download (PDF) |
| Infliximab Injectable (Inflectra®, Remicade®, Renflexis™) | Download (PDF) |
| Insulin Delivery Devices and Continuous Glucose Monitoring Systems - Revised 5/10/19 | Download (PDF) |
| Interspinous Distraction Devices | Download (PDF) |
| Intrastromal Corneal Ring Segments for Keratoconus | Download (PDF) |
| Intravenous Immune Globulins (immune globulin) | Download (PDF) |
| Intravitreal Injections/Implants | Download (PDF) |
| Istodax (romidepsin) | Download (PDF) |
| Ixempra (ixabepilone) | Download (PDF) |
| J | Download (PDF) |
|---|---|
| Jevtana (cabazitaxel) | Download (PDF) |
| K | Download (PDF) |
|---|---|
| Kadcyla® (ado-trastuzumab emtansine) | Download (PDF) |
| Kalbitor (ecallantide) | Download (PDF) |
| Kanuma (sebelipase alfa) | Download (PDF) |
| Keytruda® (pembrolizumab) | Download (PDF) |
| Khapzory (levoleucovorin) - New: 4/1/19 | Download (PDF) |
| Krystexxa (pegloticase) | Download (PDF) |
| Kymriah™ (tisagenlecleucel) | Download (PDF) |
| Kyprolis (carfilzomib) | Download (PDF) |
| L | Download (PDF) |
|---|---|
| Lartruvo (olaratumab) | Download (PDF) |
| Lemtrada® (alemtuzumab) | Download (PDF) |
| Leukine® (sargramostim) | Download (PDF) |
| Libtayo (cemiplimab-rwlc) | Download (PDF) |
| Lipoprotein Subclassification Testing for Screening, Evaluation and Monitoring of Cardiovascular Disease | Download (PDF) |
| Liposomal doxorubicin (Doxil & Lipodox) | Download (PDF) |
| Lumbar Fusion and Intervertebral Fusion Devices | Download (PDF) |
| Lumizyme (alglucosidase alfa) | Download (PDF) |
| Lumoxiti (moxetumomab pasudotox-tdfk) | Download (PDF) |
| Lung Volume Reduction Surgery | Download (PDF) |
| Lutathera® (lutetium Lu 177 dotatate) | Download (PDF) |
| Luxturna™ (Voretigene neparvovec) — Medicaid | Download (PDF) |
| Lyme Disease Diagnosis and Treatment | Download (PDF) |
| Lymphedema Treatment | Download (PDF) |
| M | Download (PDF) |
|---|---|
| Marqibo® (vincristine sulfate liposomal) | Download (PDF) |
| Mechanical Stretching Devices | Download (PDF) |
| Medical Necessity Guidelines: Experimental, Investigational or Unproven Services - Revised 6/14/19 | Download (PDF) |
| Mepsevii (vestronidase alfa-vjbk) | Download (PDF) |
| Metoclopramide and Ondansetron Infusion for Hyperemesis Gravidarum | Download (PDF) |
| Mozobil (plerixafor) | Download (PDF) |
| Mvasi (bevacizumab-awwb) | Download (PDF) |
| MYvantage® Hereditary Comprehensive Cancer Panel | Download (PDF) |
| Mylotarg (gemtuzumab ozogamicin) | Download (PDF) |
| N | Download (PDF) |
|---|---|
| Naglazyme (galsulfase) | Download (PDF) |
| Neulasta® (pegfilgrastim) | Download (PDF) |
| Neuropsychological Testing | Download (PDF) |
| Neurotoxins (Botox®, Dysport®, Myobloc® and Xeomin®) | Download (PDF) |
| Neupogen® (filgrastim) | Download (PDF) |
| Non-invasive H pylori Testing | Download (PDF) |
| Noncoronary Vascular Stents - Revised 6/14/19 | Download (PDF) |
| Nplate (romiplostim) | Download (PDF) |
| Nucala® (mepolizumab) | Download (PDF) |
| Nuchal Translucency Screening for Down Syndrome | Download (PDF) |
| Nulojix (belatacept) | Download (PDF) |
| Nutritional Counseling Services | Download (PDF) |
| O | Download (PDF) |
|---|---|
| Obstructive Sleep Apnea Diagnosis and Treatment - Revised 7/12/19 | Download (PDF) |
| Ocrevus™ (ocrelizumab) | Download (PDF) |
| Ocular Photoscreening - New 7/15/19 | Download (PDF) |
| Off-Label Use of FDA-Approved Drugs and Biologicals | Download (PDF) |
| Onivyde (irinotecan liposome) | Download (PDF) |
| Onpattro (patisiran) | Download (PDF) |
| Opdivo® (nivolumab) | Download (PDF) |
| Orencia (abatacept) | Download (PDF) |
| Orthognathic Surgery | Download (PDF) |
| Orthopedic Footwear | Download (PDF) |
| Osteochondral Grafting | Download (PDF) |
| Osteogenesis Stimulators - Revised 7/12/19 | Download (PDF) |
| Otoacoustic Emission Testing | Download (PDF) |
| Outpatient Cardiac Rehabilitation | Download (PDF) |
| P | Download (PDF) |
|---|---|
| Pain Management | Download (PDF) |
| Pancreatic Islet Cell Transplantation for Chronic Pancreatitis | Download (PDF) |
| Parsabiv (Etelcalcetide) - New 4/1/19 | Download (PDF) |
| Pasireotide (Signifor® LAR) | Download (PDF) |
| Pasteurized Donor Human Breast Milk (PDHM) | Download (PDF) |
| Peripheral Nerve Blocks | Download (PDF) |
| Periurethral Bulking Agents for Urinary Incontinence - Revised 5/10/19 | Download (PDF) |
| Perjeta (pertuzumab) | Download (PDF) |
| Phototherapy, Photochemotherapy and Photodynamic Therapy for Dermatologic Conditions | Download (PDF) |
| Polivy (polatuzumab vedotin) | Download (PDF) |
| Portrazza (necitumumab) | Download (PDF) |
| Posterior Tibial Nerve Stimulation for Voiding Dysfunction - Revised 7/12/19 | Download (PDF) |
| Poteligeo (mogamulizumab-kpkc) | Download (PDF) |
| Probuphine (buprenorphine) | Download (PDF) |
| Proleukin (aldesleukin) | Download (PDF) |
| Prolia®/Xgeva® (denosumab) | Download (PDF) |
| Prostatic Urethral Lift (PUL) | Download (PDF) |
| PROVENGE® (sipuleucel-T) | Download (PDF) |
| Pulmonary Arterial Hypertension (Remodulin, Tyvaso, Veletri, Ventavis) | Download (PDF) |
| Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions | Download (PDF) |
| Q | Download (PDF) |
|---|---|
| Qutenza (capsaicin) | Download (PDF) |
| R | Download (PDF) |
|---|---|
| Radicava (Edaravone) | Download (PDF) |
| Radiofrequency Ablation for Spinal Pain | Download (PDF) |
| Radiofrequency Ablation for Tumors - Revised 5/10/19 | Download (PDF) |
| Recurrent Pregnancy Loss | Download (PDF) |
| Relistor (methylnatrexone) | Download (PDF) |
| Relizorb (immobilized lipase) Cartridge | Download (PDF) |
| Revcovi (Elapegademase-lvlr) - New 4/1/19 | Download (PDF) |
| Rhinoplasty | Download (PDF) |
| RiaSTAP (fibrinogen) | Download (PDF) |
| Rituxan Hycela (rituximab and hyaluronidase Human) | Download (PDF) |
| Rituximab Injectable (Rituxin, Truxima) | Download (PDF) |
| Ruconest (C1 esterase inhibitor [recombinant]) | Download (PDF) |
| S | Download (PDF) |
|---|---|
| Sacroiliac Joint Fusion | Download (PDF) |
| Sandostatin® LAR (octreotide) | Download (PDF) |
| Selective Internal Radiation Therapy | Download (PDF) |
| Septoplasty | Download (PDF) |
| Simponi Aria (golimumab) | Download (PDF) |
| Site of Service Utilization - Commercial/Medicaid - New 9/1/19 | Download (PDF) |
| Soliris® (eculizumab) | Download (PDF) |
| Somatuline Depot (lanreotide) | Download (PDF) |
| Specialty Outpatient Day-Hospital Services | Download (PDF) |
| Speech-Language Pathology - Interventional Services for Autism Spectrum Disorders | Download (PDF) |
| Spinraza™ (Nusinersen) | Download (PDF) |
| Spravato (esketamine hydrochloride) | Download (PDF) |
| Stelara® (ustekinumab) | Download (PDF) |
| Stereotactic Radiosurgery and Proton Beam Therapy | Download (PDF) |
| Subcutaneous immune globulins (SCIG): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia, Cuvitru | Download (PDF) |
| Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) | Download (PDF) |
| Supprelin LA (histrelin acetate) | Download (PDF) |
| Surgical Correction of Chest Wall Deformities | Download (PDF) |
| Sylvant (siltuximab) | Download (PDF) |
| Synagis® (Palivizumab) | Download (PDF) |
| Synribo (omacetaxine) | Download (PDF) |
| T | Download (PDF) |
|---|---|
| Tecentriq (atezolizumab) | Download (PDF) |
| Telehealth — Commercial/Medicaid | Download (PDF) |
| Temodar (temozolomide) | Download (PDF) |
| Tepadina (thiotepa) | Download (PDF) |
| Therapeutic Shoes for Diabetics | Download (PDF) |
| Thyrogen (thyrotropine alfa) | Download (PDF) |
| Topical Oxygen Wound Therapy (Medicaid/FHP) | Download (PDF) |
| Torisel (temsirolimus) | Download (PDF) |
| Total Ankle Replacement | Download (PDF) |
| Transcatheter Aortic Valve Replacement - Revised 5/10/19 | Download (PDF) |
| Transurethral Radiofrequency Micro-Remodeling for Female Stress Urinary Incontinence | Download (PDF) |
| Trastuzumab Injection (Herceptin®, Herceptin Hylecta®, Herzuma®, Ontruzant®, Ogivri®) | Download (PDF) |
| Tremfya (guselkumab) | Download (PDF) |
| Trogarzo (Ibalizumab-uiyk) | Download (PDF) |
| Tysabri (natalizumab) | Download (PDF) |
| U | Download (PDF) |
|---|---|
| Ultomiris (Ravulizumab-cwvz) - New 7/1/19 | Download (PDF) |
| Unituxin™ (dinutuximab) | Download (PDF) |
| Urine Drug/Alcohol Testing | Download (PDF) |
| V | Download (PDF) |
|---|---|
| Vacuum-Assisted Wound Closure | Download (PDF) |
| Vagus Nerve Stimulation for Epilepsy | Download (PDF) |
| Vantas® (histrelin acetate) | Download (PDF) |
| Varicose Vein Treatment | Download (PDF) |
| Varubi (rolapitant) Intravenous | Download (PDF) |
| Vectibix® (panitumumab) | Download (PDF) |
| Velcade (bortezomib) | Download (PDF) |
| Vertical Expandable Prosthetic Titanium Rib (VEPTR) | Download (PDF) |
| Vimizim (elosulfase) | Download (PDF) |
| Virtual Colonoscopy (CT colonography) | Download (PDF) |
| Visual Electrophysiology Testing - Revised 7/12/19 | Download (PDF) |
| Visual Evoked Potential Testing for Pediatric Populations in the Primary Care Setting | Download (PDF) |
| Vitamin D Deficiency Testing | Download (PDF) |
| Vpriv (velaglucerase alfa) | Download (PDF) |
| Vyxeos™ (daunorubicin and cytarabine) | Download (PDF) |
| W | Download (PDF) |
|---|---|
| Wigs — Medicaid and Essential Plans/Direct Pay (Bronze, Silver, Gold, Platinum) | Download (PDF) |
| X | Download (PDF) |
|---|---|
| Xiaflex (collagenase clostridium histolyticum) | Download (PDF) |
| Xofigo for Castration-Resistant Prostate Cancer | Download (PDF) |
| Xolair® (omalizumab) | Download (PDF) |
| Y | Download (PDF) |
|---|---|
| Yervoy™ (ipilimumab) | Download (PDF) |
| Yescarta (axicabtagene ciloleucel) | Download (PDF) |
| Yondelis (trabectedin) | Download (PDF) |
| Z | Download (PDF) |
|---|---|
| Zaltrap (ziv-aflibercept) | Download (PDF) |
| Zevalin (ibritumomab tiuxetan) | Download (PDF) |
| Zilretta (triamcinolone acetonide extended release injection) | Download (PDF) |
| Zinplava (bezlotoxumab) | Download (PDF) |
| Zoledronic acid (Zometa®, Reclast®) | Download (PDF) |
| Zolgensma (onasemnogene abeparvovec-xioi) | Download (PDF) |
| Zulresso (brexanolone) | Download (PDF) |
