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 - Revised  9/13/19 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), Zirabev® (bevacizumab-bvcr) 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 - Revised 9/13/19 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)
Tegsedi (inotersen) 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)