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Medical Policies
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:
- Behavioral Health
- CMS Local and National Coverage Determinations
- ConnectiCare’s Medical Policies
- EmblemHealth Plan, Inc.
- EmblemHealth Spine Surgery and Pain Management Therapies Program
- Enterprise Pharmacy Medical Policies
- HealthCare Partners (HCP) Prior Authorization Process
- Healthplex Dental Policies
- Health Insurance Plan of Greater New York (HIP)/EmblemHealth Insurance Company
- MCG
- Medical Oncology Policies
Also see our Medical Technologies Database.
| 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) |
| B back to top | Download (PDF) |
|---|---|
| Balloon Sinuplasty | Download (PDF) |
| Bariatric Surgery | Download (PDF) |
| Biomagnetic Therapy | Download (PDF) |
| Blepharoplasty | 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) |
| 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) |
| 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) |
|---|---|
| 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) |
|---|---|
| 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) |
| Osteochondral Grafting | Download (PDF) |
| Osteogenesis Stimulators (Does Not Apply to ConnectiCare) | 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) |
|---|---|
| Varicose Vein Treatment | Download (PDF) |
| Vertical Expandable Prosthetic Titanium Rib (VEPTR) | Download (PDF) |
JP69830 01/26