Medical Policies

Medical Policies are listed in alphabetical order


A back to top 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)
Acupuncture for Chronic Lower Back Pain - Medicare Download (PDF)
Adakveo (crizanlizumab injection) Download (PDF)
Adasuve® (loxapine) Download (PDF)
Adcetris (brentuximab vedotin)  Download (PDF)
Aduhelm™ (aducanumab-avwa) Download (PDF)
Ajovy (fremanezumab-vfrm) Download (PDF)
Akynzeo (fosnetupitant and palonosetron) Injection 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)
Amondys 45™ (casimersen intravenous infusion) Effective Download (PDF)
Analysis of KRAS Status - Revised 9/10/2021 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 - Revised 10/8/2021 Download (PDF)
Arzerra (ofatumumab) Download (PDF)
Asparlas (calaspargase pegol-mknl) 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 back to top Download (PDF)
Balloon Sinuplasty  - Revised 9/10/2021 Download (PDF)
Barhemsys (amisulpride) Download (PDF)
Bariatric Surgery 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)
Blenrep (belantamab mafodotin-blmf) Download (PDF)
Blepharoplasty Download (PDF)
Blincyto™ (blinatumomab)  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 - Revised 10/8/2021 Download (PDF)
Breast Reduction Mammoplasty Download (PDF)
Breyanzi (lisocabtagene maraleucel) Download (PDF)
Brineura (cerliponase alfa) Download (PDF)
C back to top Download (PDF)
Cabenuva (cabotegravir rilpivirine) Download (PDF)
Cablivi (caplacizumab-yhdp) Download (PDF)
Campath® (Alemtuzumab) Download (PDF)
Canaloplasty and Viscocanalostomy Download (PDF)
Capsule Endoscopy (camera pill) Download (PDF)
Cardiac Event Monitors Download (PDF)
Carrier Screening for Parents or Prospective Parents - Revised 9/10/2021 Download (PDF)
Cerezyme (imiglucerase) Download (PDF)
Chemical Peels 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: Leukine® (sargramostim) Download (PDF)
Colony Stimulating Factors: Neulasta® (pegfilgrastim) Download (PDF)
Colony Stimulating Factors: Neupogen®, Granix® and Zarxio® (filgrastim) Download (PDF)
Colony Stimulating Factors: Nivestym™ (filgrastim-aafi) Download (PDF)
Colony Stimulating Factors: Udenyca (pegfilgrastim-cbqv) Download (PDF)
Colony Stimulating Factors: Ziextenzo (pegfilgrastim-bmez) Download (PDF)
Continuous Passive Motion Devices Download (PDF)
Cortical Stimulation for Epilepsy (NeuroPace®) - Revised 10/8/2021 Download (PDF)
Cosela™ (trilaciclib injection) powder for injection Download (PD]F)
Cosmetic Surgery Procedures Download (PD]F)
Cresemba® (isavuconazonium sulfate) 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 - Revised 10/8/2021 Download (PDF)
Cytogam (cytomegalovirus immune globulin, human) Download (PDF)
D back to top Download (PDF)
Dacogen (decitabine) Download (PDF)
DANYELZA® (naxitamab-gqgk) injection 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 back to top Download (PDF)
EEG - Ambulatory Monitoring Electroencephalogram Download (PDF)
EEG - Noninvasive Electroencephalogram - COMMERCIAL/MEDICAID Download (PDF)
Elaprase® (idursulfase) Download (PDF)
Elelyso (taliglucerase alfa) Download (PDF)
Eloxatin (oxaliplatin) Download (PDF)
Elzonris (Tagraxofusp-erzs) Download (PDF)
Empliciti (elotuzumab) Download (PDF)
Enhertu (fam-trastuzumab deruxtecan-nxki) 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, Retacrit (epoetin alfa) Download (PDF)
Eteplirsen (Exondys 51™) Download (PDF)
Evenity (romosozumab-aqqg) Download (PDF)
External Breast Prosthesis /Bra Download (PDF)
F back to top 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)
Fensolvi (leuprolide_acetate) Download (PDF)
Fetroja® (cefiderocol) Download (PDF)
Firazyr (icatibant) Download (PDF)
Folotyn (pralatrexate) Download (PDF)
Foot Surgery — Bunion/Hammertoe/Metatarsophalangeal Joint (Commercial) Download (PDF)
Functional Endoscopic Sinus Surgery (FESS) Download (PDF)
Fusilev (levoleucovorin) Download (PDF)
G back to top Download (PDF)
Gamifant (Emapalumab-lzsg) Download (PDF)
gammaCore Sapphire CV for the Coronavirus Disease 2019 (COVID-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 - Revised 10/19/2021 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 Frontotemporal Dementia (FTD) Download (PDF)
Genetic Testing for PTEN Hamartoma Tumor Syndrome Download (PDF)
Givlaari (givosiran) Download (PDF)
Glaucoma Surgery Download (PDF)
H back to top Download (PDF)
H.P. Acthar® Gel Download (PDF)
Haegarda® (C1 esterase inhibitor human) and Takhzyro® (lanadelumab-flyo) 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 Infusion Therapy—Registered Nurse 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 back to top 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 – Commercial Download (PDF)
Infliximab Injectable (Avsola, Inflectra®, Remicade®, Renflexis™) Download (PDF)
Infugem (gemcitabine) Download (PDF)
Insulin Delivery Devices and Continuous Glucose Monitoring Systems Download (PDF)
Interspinous Distraction Devices Download (PDF)
Intrastromal Corneal Ring Segments for Keratoconus - Revised 9/10/2021 Download (PDF)
Intravenous Immune Globulins (immune globulin) Download (PDF)
Intravitreal Injections/Implants Download (PDF)
Istodax (romidepsin) Download (PDF)
Ixempra (ixabepilone) Download (PDF)
J back to top Download (PDF)
Jelmyto (mitomycin solution for pyelocalyceal administration) Download (PDF)
Jemperli (dostarlimab-gxly) Download (PDF)
Jevtana (cabazitaxel) Download (PDF)
K back to top Download (PDF)
Kadcyla® (ado-trastuzumab emtansine) Download (PDF)
Kalbitor (ecallantide) Download (PDF)
Kanuma (sebelipase alfa) Download (PDF)
Keytruda® (pembrolizumab) Download (PDF)
Khapzory (levoleucovorin) Download (PDF)
Krystexxa (pegloticase) Download (PDF)
Kymriah™ (tisagenlecleucel) Download (PDF)
Kyprolis (carfilzomib) Download (PDF)
L back to top Download (PDF)
Lartruvo (olaratumab) Download (PDF)
Lemtrada® (alemtuzumab) 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)
Lutathera® (lutetium Lu 177 dotatate) Download (PDF)
Luxturna™ (Voretigene neparvovec) Download (PDF)
Lyme Disease Diagnosis and Treatment Download (PDF)
Lymphedema Treatment Download (PDF)
M back to top Download (PDF)
Marqibo® (vincristine sulfate liposomal) Download (PDF)
Margenza (margetuimab) Download (PDF)
Mechanical Stretching Devices Download (PDF)
Medical Necessity Guidelines: Experimental, Investigational or Unproven Services Download (PDF)
Mepsevii (vestronidase alfa-vjbk) Download (PDF)
Metoclopramide and Ondansetron Infusion for Hyperemesis Gravidarum Download (PDF)
Monjuvi (tafasitamab-cxix) 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 back to top Download (PDF)
Naglazyme (galsulfase) Download (PDF)
Neuropsychological Testing Download (PDF)
Neurotoxins (Botox®, Dysport®, Myobloc® and Xeomin®) Download (PDF)
Noninvasive H pylori Testing Download (PDF)
Noninvasive Prenatal Testing (NIPT) for Fetal Aneuploidy Download (PDF)
Noncoronary Vascular Stents 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)
NYVEPRIA™ (pegfilgrastim-apgf) Download (PDF)
O back to top Download (PDF)
Obstructive Sleep Apnea Diagnosis and Treatment Download (PDF)
Ocrevus™ (ocrelizumab) Download (PDF)
Ocular Photoscreening 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 Download (PDF)
Otoacoustic Emission Testing Download (PDF)
Outpatient Cardiac Rehabilitation Download (PDF)
Oxlumo™ (lumasiran) Download (PDF)
P back to top Download (PDF)
Padcev (enfortumab vedotin-ejfv) Download (PDF)
Pain Management Download (PDF)
Pancreatic Islet Cell Transplantation for Chronic Pancreatitis Download (PDF)
Parsabiv (Etelcalcetide) Download (PDF)
Pasireotide (Signifor® LAR) Download (PDF)
Pasteurized Donor Human Breast Milk (PDHM) Download (PDF)
Pemfexy (pemetrexed injection), for intravenous use Download (PDF)
Peripheral Nerve Blocks Download (PDF)
Periurethral Bulking Agents for Urinary Incontinence Download (PDF)
Perjeta (pertuzumab) Download (PDF)
Phesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf 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 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 back to top Download (PDF)
Qutenza (capsaicin) Download (PDF)
R back to top Download (PDF)
Radicava (Edaravone) Download (PDF)
Radiofrequency Ablation for Spinal Pain Download (PDF)
Radiofrequency Ablation of Tumors Download (PDF)
Reblozyl (luspatercept-aamt) Download (PDF)
Recurrent Pregnancy Loss Download (PDF)
Relistor (methylnatrexone) Download (PDF)
Relizorb (immobilized lipase) Cartridge Downlo
Revcovi (Elapegademase-lvlr) Download (PDF)
Rhinoplasty - Revised 9/10/2021 Download (PDF)
RiaSTAP (fibrinogen) Download (PDF)
Rituxan Hycela (rituximab and hyaluronidase Human) Download (PDF)
Rituximab Injectable (Rituxan®, Ruxience®, Truxima®) Download (PDF)
Ruconest (C1 esterase inhibitor [recombinant]) Download (PDF)
S back to top Download (PDF)
Sacroiliac Joint Fusion Download (PDF)
Sandostatin® LAR (octreotide) Download (PDF)
Sarclisa® (isatuximab) Download (PDF)
Selective Internal Radiation Therapy Download (PDF)
Septoplasty Download (PDF)
Simponi Aria (golimumab) Download (PDF)
Site of Service Utilization 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) Downlo
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)
Tback to top Download (PDF)
Tecartus (brexucabtagene autoleucel) Download (PDF)
Tecentriq (atezolizumab) Download (PDF)
Tegsedi (inotersen) Download (PDF)
Telehealth — Commercial/Medicaid Download (PDF)
Temodar (temozolomide) Download (PDF)
Tepadina (thiotepa) Download (PDF)
Tepezza® (teprotumumab-trbw) Download (PDF)
Testing for Coronavirus Disease 2019 (COVID-19) 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 10/8/2021 Download (PDF)
Transurethral Radiofrequency Micro-Remodeling for Female Stress Urinary Incontinence - Revised 8/13/2021 Download (PDF)
Trastuzumab Injection (Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ontruzant, Ogivri, Trazimera) Download (PDF)
Tremfya (guselkumab) Download (PDF)
Trodelvy™ (sacituzumab govitecan-hziy) Download (PDF)
Trogarzo (Ibalizumab-uiyk) Download (PDF)
Tysabri (natalizumab) Download (PDF)
U back top Download (PDF)
Ultomiris (Ravulizumab-cwvz) Download (PDF)
Unituxin™ (dinutuximab) Download (PDF)
Uplizna (inebilizumab-cdon) Download (PDF)
Urine Drug/Alcohol Testing - Commercial/Medicaid Download (PDF)
V back to top Download (PDF)
Vacuum-Assisted Wound Closure Download (PDF)
Vantas® (histrelin acetate) Download (PDF)
Varicose Vein Treatment Download (PDF)
Vectibix® (panitumumab) Download (PDF)
Velcade (bortezomib) Download (PDF)
Vertical Expandable Prosthetic Titanium Rib (VEPTR) Download (PDF)
Viltepso (viltolarsen) Download (PDF)
Vimizim (elosulfase)] Download (PDF)
Virtual Colonoscopy (CT colonography) Download (PDF)
Visual Electrophysiology Testing - Revised 9/10/2021 Download (PDF)
Vitamin D Deficiency Testing Download (PDF)
Vpriv (velaglucerase alfa) Download (PDF)
Vyepti™ (eptinezumab-jjmr) Download (PDF)
VYONDYS 53® (golodirsen) Download (PDF)
Vyxeos™ (daunorubicin and cytarabine) Download (PDF)
W back to top Download (PDF)
Wigs — Medicaid and Essential Plans/Direct Pay (Bronze, Silver, Gold, Platinum) Download (PDF)
X back to top Download (PDF)
Xiaflex (collagenase clostridium histolyticum) Download (PDF)
Xofigo for Castration-Resistant Prostate Cancer Download (PDF)
Xolair® (omalizumab) Download (PDF)
Y back to top Download (PDF)
Yervoy™ (ipilimumab) Download (PDF)
Yescarta (axicabtagene ciloleucel) Download (PDF)
Yondelis (trabectedin) Download (PDF)
Z back to top Download (PDF)
Zaltrap (ziv-aflibercept) Download (PDF)
Zepzelca (lurbinectedin) 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)
Zynlonta (loncastuximab-tesirine) Download (PDF)