The Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, Utilization Review Guidelines and corresponding update bulletins for UnitedHealthcare Community Plan are listed below.
Open the section below to view more information.
A monthly notice of recently approved and/or revised Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines (CDGs), and Utilization Review Guidelines (URGs) is provided below for your review. We publish a new announcement on the first calendar day of every month.
The appearance of a health service (e.g., test, drug, device or procedure) in the Medical Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Medical Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
For Kentucky, click here to view the Medical Policy Update Bulletins.
Last Published 04.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines (CDG), and/or Utilization Review Guidelines (URG).
Last Published 05.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines (CDG), and/or Utilization Review Guidelines (URG).
Last Published 06.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines (CDG), and/or Utilization Review Guidelines (URG).
Last Published 06.01.2021
This Community Plan medical policy library does not apply to the following states; click the link to view the applicable Medical & Drug Policies and Coverage Determination Guidelines:
For Louisiana, click here to view MCG criteria for the top Outpatient procedures and Admission diagnoses.
UnitedHealthcare has developed Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines to assist us in administering health benefits. These policies and guidelines are provided for informational purposes and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
Our Medical Policies and Medical Benefit Drug Policies express our determination of whether a health service (e.g., test, device or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.
Coverage Determination Guidelines are used to determine whether a service falls within a benefit category or is excluded from coverage. Coverage Determination Guidelines may address such matters as whether services are skilled versus custodial, or reconstructive versus cosmetic.
Utilization Review Guidelines apply clinical practice guidelines to determine whether the health care services provided or planned for an individual member are the most appropriate and cost-effective services under the specific circumstances.
Benefit coverage for health services is determined by the member specific benefit plan document, such as a Certificate of Coverage, Schedule of Benefits, or Summary Plan Description, and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these policies and guidelines.
For California members, note that the materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.
Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies and guidelines is believed to be accurate and current as of the date of publication and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, such as the InterQual® criteria, to assist us in administering health benefits. The InterQual® criteria are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines are the property of UnitedHealthcare. Unauthorized copying, use, and distribution of this information are strictly prohibited. The InterQual® criteria are proprietary to Change Healthcare and are not published on this website.
When these policies are used to determine medical necessity, clinical guidelines will be applied in the following order:
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Last Published 06.01.2021
Effective Date: 12.01.2020 – This policy addresses intramuscular and subcutaneous injection of 17-alpha-hydroxyprogesterone caproate, commonly called 17P or Makena®. Applicable Procedure Codes: J1726, J1729, J2675.
Last Published 05.01.2021
Effective Date: 02.01.2020 – This policy addresses thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 64625, 64633, 64634, 64635, 64636, 64999.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 64625, 64633, 64634, 64635, 64636, 64999.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 27299, 64625, 64633, 64634, 64635, 64636, 64999.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses the use of levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound ablation (MRgFUS), and ultrasound-guided radiofrequency ablation. Applicable Procedure Codes: 0071T, 0072T, 0404T, 37243, 58578, 58674, 58999, J7296, J7297, J7298, J7301, J7306, S4981.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses the use of levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound ablation (MRgFUS), and ultrasound-guided radiofrequency ablation. Applicable Procedure Codes: 0071T, 0072T, 0404T, 37243, 58578, 58674, 58999, J7296, J7297, J7298, J7301, J7306, S4981.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses the use of levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound ablation (MRgFUS), and ultrasound-guided radiofrequency ablation. Applicable Procedure Codes: 0071T, 0072T, 0404T, 37243, 58578, 58674, 58999, J7296, J7297, J7298, J7301, J7306, S4981.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Actemra® (tocilizumab) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, systemic juvenile idiopathic arthritis, cytokine release syndrome, acute graft-versus-host disease, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J3262.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Adakveo® (crizanlizumab-tmca) to reduce the frequency of vasoocclusive crises in patients with sickle cell disease. Applicable Procedure Code: J0791.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses airway clearance devices, such as high-frequency chest wall oscillation systems, acoustical or mechanical percussor, positive expiratory pressure and aerosol drug delivery system combination device, and intrapulmonary percussive ventilation (IPV) devices. Applicable Procedure Codes: A7025, A7026, E0481, E0483, E1399.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses airway clearance devices, such as high-frequency chest wall oscillation systems, acoustical or mechanical percussor, positive expiratory pressure and aerosol drug delivery system combination device, and intrapulmonary percussive ventilation (IPV) devices. Applicable Procedure Codes: A7025, A7026, E0481, E0483, E1399.
Last Published 06.01.2021
Effective Date: 12.01.2020 – This policy addresses alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®-C, and Zemaira®) for chronic augmentation and maintenance therapy of emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI)/alpha1-antitrypsin (AAT) deficiency. Applicable Procedure Codes: J0256, J0257.
Last Published 05.01.2021
Effective Date: 09.01.2020 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.
Last Published 05.01.2021
Effective Date: 07.01.2019 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services. Applicable Procedure Codes: A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0998, A0999, S0207, S0208, S9960, S9961, T2007.
Last Published 05.01.2021
Effective Date: 09.01.2020 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of Amondys 45™ (casimersen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Codes: C9399, J3490, and J3590.
Last Published 05.01.2021
Effective Date: 12.01.2019 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses autologous chondrocyte transplantation (ACT), osteochondral autograft and allograft transplantation, microfracture repair of the knee, and focal articular cartilage repair. Applicable Procedure Codes: 27412, 27415, 27416, 28446, 29866, 29867, 29879, J7330, S2112.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses autologous chondrocyte transplantation (ACT), osteochondral autograft and allograft transplantation, and microfracture repair of the knee. Applicable Procedure Codes: 27412, 27415, 27416, 28446, 29866, 29867, 29879, J7330, S2112.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.
Last Published 05.01.2021
Effective Date: 07.01.2020 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.
Last Published 05.13.2021
Effective Date: 05.01.2021 – This policy addresses home sleep apnea testing, attended full-channel nocturnal polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, and attended PAP titration. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses home sleep apnea testing, attended full-channel nocturnal polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, and attended PAP titration. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 27599.
Last Published 05.01.2021
Effective Date: 01.01.2019 – This policy addresses autologous chondrocyte transplantation (ACT). Applicable Procedure Codes: 27412, J7330, S2112.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298, 31299.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, sleeve gastrectomy, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, sleeve gastrectomy, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, sleeve gastrectomy, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Benlysta® (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN). Applicable Procedure Code: J0490.
Last Published 05.01.2021
Effective Date: 08.01.2020 – This policy addresses upper and lower eyelid blepharoplasty, upper eyelid blepharoptosis repair, brow ptosis, eyelid surgery with an anophthalmic socket, ectropion or punctal eversion, entropion, lid retraction surgery, canthoplasty/canthopexy, and repair of floppy eyelid syndrome (FES).
Last Published 05.01.2021
Effective Date: 04.01.2020 – This policy addresses upper and lower eyelid blepharoplasty, upper eyelid blepharoptosis repair, brow ptosis, eyelid surgery with an anophthalmic socket, ectropion or punctal eversion, entropion, lid retraction surgery, canthoplasty/canthopexy, and repair of floppy eyelid syndrome (FES).
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses upper and lower eyelid blepharoplasty, upper eyelid blepharoptosis repair, brow ptosis, eyelid surgery with an anophthalmic socket, ectropion or punctal eversion, entropion, lid retraction surgery, canthoplasty/canthopexy, and repair of floppy eyelid syndrome (FES).
Last Published 05.01.2021
Effective Date: 02.01.2020 – This policy addresses autographs, allografts, demineralized bone matrix (DBM), bone morphogenetic proteins (BMP), and other bone or soft tissue healing and fusion enhancement products. Applicable Procedure Codes: 20930, 20931, 20932, 20933, 20934, 22558, 22585, 22899, Q4100, Q4149, Q4186, Q4187.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses autographs, allografts, demineralized bone matrix (DBM), bone morphogenetic proteins (BMP), and other bone or soft tissue healing and fusion enhancement products. Applicable Procedure Codes: 20930, 20931, 20932, 20933, 20934, 22558, 22585, 22899, Q4100, Q4149, Q4186, Q4187.
Last Published 05.01.2021
Effective Date: 09.01.2020 – This policy addresses bone or soft tissue healing and fusion enhancement products/systems. Applicable Procedure Codes: 20930, 20931, 20932, 20933, 20934, 22558, 22585, 22899.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Applicable Procedure Codes: J0585, J0586, J0587, J0588.
Last Published 05.01.2021
Effective Date: 05.01.2019 – This policy addresses breast imaging, including digital mammography, magnetic resonance imaging (MRI), ultrasound, automated breast ultrasound system, computer-aided detection (CAD), computer-aided tactile breast imaging, electrical impedance scanning (EIS), magnetic resonance elastography (MRE), and scintimammography. Applicable Procedure Codes: 0422T, 76376, 76377, 76391, 76498, 76499, 76641, 76642, 77046, 77047, 77048, 77049, 77065, 77066, 77067, S8080.
Last Published 05.01.2021
Effective Date: 05.01.2019 – This policy addresses breast imaging, including digital mammography, magnetic resonance imaging (MRI), ultrasound, automated breast ultrasound system, computer-aided detection (CAD), computer-aided tactile breast imaging, electrical impedance scanning (EIS), magnetic resonance elastography (MRE), and scintimammography. Applicable Procedure Codes: 0422T, 76376, 76377, 76391, 76498, 76499, 76641, 76642, 77046, 77047, 77048, 77049, 77065, 77066, 77067, S8080.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses breast imaging, including digital mammography, magnetic resonance imaging (MRI), ultrasound, automated breast ultrasound system, computer-aided detection (CAD), computer-aided tactile breast imaging, electrical impedance scanning (EIS), magnetic resonance elastography (MRE), and molecular breast imaging. Applicable Procedure Codes: 0422T, 76376, 76377, 76391, 76498, 76499, 76641, 76642, 77046, 77047, 77048, 77049, 77065, 77066, 77067, S8080.
Last Published 05.01.2021
Effective Date: 03.01.2020 – This policy addresses breast reconstruction post-mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19301, 19302, 19303, 19305, 19306, 19307, 19316, 19318, 19324, 19325, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses breast reconstruction post-mastectomy.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses breast reconstruction post-mastectomy and for treatment of Poland syndrome. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19301, 19302, 19303, 19305, 19306, 19307, 19316, 19318, 19325, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Last Published 05.01.2021
Effective Date: 03.01.2020 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Last Published 05.01.2021
Effective Date: 11.01.2019 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.
Last Published 05.01.2021
Effective Date: 11.01.2019 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.
Last Published 10.01.2020
Effective Date: 10.01.2020 – This policy addresses the use of Brineura® (cerliponase alfa) in pediatric patients with late infantile neuronal ceroid lipofuscinosis (LINCL). Applicable Procedure Code: J0567.
Last Published 06.01.2021
Effective Date: 09.01.2020 – This policy addresses the use of Brineura® (cerliponase alfa) in pediatric patients with late infantile neuronal ceroid lipofuscinosis (LINCL). Applicable Procedure Code: J0567.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.
Last Published 05.01.2021
Effective Date: 08.01.2020 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.
Last Published 06.01.2021
Effective Date: 11.01.2020 – This policy addresses the use of buprenorphine (Probuphine® and Sublocade®) for the treatment of opioid dependence/opioid use disorder. Applicable Procedure Codes: 11981, 11982, G0516, G0517, G0518, J0570, Q9991, Q9992.
Last Published 05.13.2021
Effective Date: 05.01.2021 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0295T, 0296T, 0297T, 0298T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272, 93285, 93291, 93298, E0616, G2066.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272, 93285, 93291, 93298, E0616, G2066.
Last Published 05.13.2021
Effective Date: 05.01.2021 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272, 93285, 93291, 93298, E0616, G2066.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0052U, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0052U, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0052U, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.
Last Published 05.01.2021
Effective Date: 07.01.2020 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 81412, 81443, 81479.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0168U, 81420, 81422, 81479, 81507.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0168U, 81420, 81422, 81479, 81507.
Last Published 05.01.2021
Effective Date: 08.01.2020 – This policy addresses certified nursing assistant (CNA) or home health aide (HHA) services for individuals age 21 and older. Applicable Procedure Codes: G0156, S9122, T1004, T1021.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses chemosensitivity and chemoresistance assays in cancer. Applicable Procedure Codes: 0083U, 0564T, 81535, 81536, 86849, 89240.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses chemosensitivity and chemoresistance assays in cancer. Applicable Procedure Codes: 0083U, 0564T, 81535, 81536, 86849, 89240.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses genome-wide comparative genomic hybridization microarray testing or single nucleotide polymorphism (SNP) chromosomal microarray analysis. Applicable Procedure Codes: 0209U, 81228, 81229, 81479, S3870.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses genome-wide comparative genomic hybridization microarray testing or single nucleotide polymorphism (SNP) chromosomal microarray analysis. Applicable Procedure Codes: 0156U, 0209U, 81228, 81229, 81479, S3870.
Last Published 06.01.2021
Effective Date: 03.01.2021 – This policy addresses the use of Cimzia® (certolizumab pegol) the treatment of Crohn’s disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, and plaque psoriasis. Applicable Procedures Codes: 96372, 96401, J0717.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Last Published 05.01.2021
Effective Date: 05.01.2020 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Last Published 05.01.2021
Effective Date: 08.01.2020 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.
Last Published 05.01.2021
Effective Date: 04.01.2020 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.
Last Published 05.01.2021
Effective Date: 02.01.2019 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Soliris® (eculizumab) and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: J1300, J1303.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.
Last Published 05.01.2021
Effective Date: 12.01.2018 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.
Last Published 05.01.2021
Effective Date: 10.01.2019 – This policy addresses computer-assisted surgical navigation for musculoskeletal procedures and the use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty. Applicable Procedure Codes: 0054T, 0055T, 0396T, 20985.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses computer-assisted surgical navigation for musculoskeletal procedures and the use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty. Applicable Procedure Codes: 0054T, 0055T, 20985.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses computer-assisted surgical navigation for musculoskeletal procedures and the use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty. Applicable Procedure Codes: 0054T, 0055T, 20985.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.
Last Published 05.01.2021
Effective Date: 05.01.2020 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4226, A9274, A9276, A9277, A9278, E0784, E0787, E1399, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4226, A9274, A9276, A9277, A9278, E0784, E0787, E1399, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.
Last Published 05.07.2021
Effective Date: 05.01.2021 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4226, A9274, A9276, A9277, A9278, E0784, E0787, E1399, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4211, A4226, A9274, A9276, A9277, A9278, E0784, E0787, E1399, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses measurement of corneal hysteresis, measurement of ocular blood flow, and monitoring of intraocular pressure. Applicable Procedure Codes: 0198T, 0329T, 66999, 67299, 92145.
Last Published 05.01.2021
Effective Date: 07.01.2020 – This policy addresses measurement of corneal hysteresis, measurement of ocular blood flow, and monitoring of intraocular pressure. Applicable Procedure Codes: 0198T, 0329T, 66999, 67299, 92145.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses cosmetic and reconstructive procedures.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses cosmetic and reconstructive procedures.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses cosmetic and reconstructive procedures.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Crysvita® (burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH) and Fibroblast Growth Factor 23 (FGF23)-related hypophosphatemia in tumor-induced osteomalacia (TIO). Applicable Procedure Code: J0584.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Crysvita® (burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH) and Fibroblast Growth Factor 23 (FGF23)-related hypophosphatemia in tumor-induced osteomalacia (TIO). Applicable Procedure Code: J0584.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.
Last Published 05.01.2021
Effective Date: 08.01.2020 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses deep brain and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses deep brain and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses conventional deep brain stimulation and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses certain specialty injectable drug products that are only covered under the pharmacy benefit, including growth hormones, insulin-like growth factors, interferon alpha, monoclonal antibodies, multiple sclerosis agents, osteoporosis treatments, and tumor necrosis factor (TNF) antagonists. Applicable Procedure Codes: 90378, J0135, J0599, J0717, J1438, J1595, J1628, J1744, J1826, J1830, J2170, J2357, J2941, J3110, J3357, J7639, J7682, J9212, Q3027, Q3028, S0145, S0148.
Last Published 06.01.2021
Effective Date: 11.01.2020 – This policy addresses the use of denosumab (Prolia® & Xgeva®). Applicable Procedure Code: J0897.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses thermal intradiscal procedures (TIPs) and percutaneous discectomy and decompression procedures for treating discogenic pain, and annulus fibrosus repair following spinal surgery. Applicable Procedure Codes: 22526, 22527, 22899, 62287, 62380, S2348.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses thermal intradiscal procedures (TIPs) and percutaneous discectomy and decompression procedures for treating discogenic pain, and annulus fibrosus repair following spinal surgery. Applicable Procedure Codes: 22526, 22527, 22899, 62287, 62380, S2348.
Last Published 05.01.2021
Effective Date: 02.01.2020 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.
Last Published 05.01.2021
Effective Date: 12.01.2019 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Last Published 05.01.2021
Effective Date: 12.01.2019 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.
Last Published 05.13.2021
Effective Date: 05.01.2021 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20975, 20979, E0747, E0748, E0749, E0760.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.
Last Published 05.01.2021
Effective Date: 11.01.2020 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses electrical stimulation and electromagnetic therapy for treating ulcers or wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.
Last Published 05.01.2021
Effective Date: 03.01.2020 – This policy addresses electrical stimulation and electromagnetic therapy for ulcers or wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses electrical stimulation and electromagnetic therapy for ulcers or wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Applicable Procedure Codes: 0278T, 63650, 63655, 63685, 64999, E0744, E0745, E0762, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Last Published 05.01.2021
Effective Date: 07.01.2019 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Applicable Procedure Codes: 0278T, 63650, 63655, 63685, 64999, E0744, E0745, E0762, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Applicable Procedure Codes: 0278T, 63650, 63655, 63685, 64999, E0744, E0745, E0762, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.
Last Published 05.01.2021
Effective Date: 04.01.2019 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Last Published 05.01.2021
Effective Date: 05.01.2020 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses outpatient emergency health care services, physician-ordered emergency department visits, and urgent care center services.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Entyvio® (vedolizumab) for the treatment of Crohn's disease, ulcerative colitis, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J3380.
Last Published 06.01.2021
Effective Date: 11.01.2020 – This policy addresses enzyme replacement therapy, including the use of Aldurazyme (laronidase), Elaprase (idursulfase), Fabrazyme (agalsidase beta), Kanuma (sebelipase alfa), Lumizyme (alglucosidase alfa), Mepsevii (vestronidase alfa-vjbk), Naglazyme (galsulfase), Revcovi (elapegademase-lvlr), and Vimizim (elosulfate alfa). Applicable Procedure Codes: J0180, J0221, J1322, J1458, J1743, J1931, J2840, J3397, J3590.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses epidural steroid and facet injections for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0230T, 0231T, 62322, 62323, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses epidural steroid and facet injections for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 62322, 62323, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses epidural steroid injections for spinal pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses functional anesthetic discography (FAD), provocative discography, epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions for the diagnosis or treatment of any type of neck, back, or spinal disorder. Applicable Procedure Codes: 62263, 62264, 62290, 64999, 72295.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses functional anesthetic discography (FAD), provocative discograph,y epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions for the diagnosis or treatment of any type of neck, back, or spinal disorder. Applicable Procedure Codes: 62263, 62264, 62290, 62291, 64999, 72285, 72295.
Last Published 05.01.2021
Effective Date: 12.01.2018 – This policy addresses epiduroscopy (including spinal myeloscopy), percutaneous and endoscopic epidural lysis of adhesions, and functional anesthetic discography (FAD) for the diagnosis or treatment of any type of neck or back pain or spinal disorder. Applicable Procedure Codes: 62263, 62264, 64999.
Last Published 06.01.2021
Effective Date: 11.01.2020 – This policy addresses the use of erythropoiesis-stimulating agents (ESAs), including Aranesp® (darbepoetin alfa), Epogen® (epoetin alfa), Mircera® (methoxy polyethylene glycol-epoetin beta [MPG-epoetin beta]), Procrit® (epoetin alfa), and Retacrit® (epoetin alfa). Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses the use of Evenity® (romosozumab-aqqg) for the treatment of osteoporosis in postmenopausal patients at high risk for fracture. Applicable Procedure Code: J3111.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of Evkeeza™ (evinacumab-dgnb) for the treatment of homozygous familial hypercholesterolemia (HoFH). Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.
Last Published 05.01.2021
Effective Date: 06.01.2019 – This policy addresses extracorporeal shock wave therapy (ESWT). Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.
Last Published 05.01.2021
Effective Date: 06.01.2019 – This policy addresses extracorporeal shock wave therapy (ESWT). Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.
Last Published 05.01.2021
Effective Date: 09.01.2020 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses facet joint injections/medial branch blocks for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.
Last Published 05.01.2021
Effective Date: 06.01.2019 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.
Last Published 05.01.2021
Effective Date: 12.01.2019 – This policy addresses surgical treatment for femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27299, 29914, 29915, 29916, 29999.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses surgical treatment for femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27299, 29914, 29915, 29916, 29999.
Last Published 05.01.2021
Effective Date: 11.01.2019 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Last Published 05.01.2021
Effective Date: 09.01.2018 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Last Published 03.01.2021
Effective Date: 03.01.2021 – This policy addresses the use of Gamifant® (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.
Last Published 06.01.2021
Effective Date: 03.01.2021 – This policy addresses the use of Gamifant® (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.
Last Published 05.01.2021
Effective Date: 06.01.2019 – This policy addresses gastric electrical stimulation therapy, manometry and rectal sensation, tone and compliance test, defecography, electrogastrography, and electroenterography. Applicable Procedure Codes: 43647, 43648, 43881, 43882, 64590, 64595, 76496, 76498, 91117, 91120, 91122, 91132, 91133.
Last Published 05.01.2021
Effective Date: 06.01.2019 – This policy addresses gastric electrical stimulation therapy, manometry and rectal sensation, tone and compliance test, defecography, electrogastrography, and electroenterography. Applicable Procedure Codes: 43647, 43648, 43881, 43882, 64590, 64595, 76496, 76498, 91117, 91120, 91122, 91132, 91133.
Last Published 05.01.2021
Effective Date: 07.01.2020 – This policy addresses gastric electrical stimulation therapy; manometry, sensation, tone, and compliance testing; defecography; and electrogastrography/electroenterography. Applicable Procedure Codes: 43647, 43648, 43881, 43882, 64590, 64595, 76496, 76498, 91117, 91120, 91122, 91132, 91133.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 0097U, 87505, 87506, 87507.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 0097U, 87505, 87506, 87507.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses gender dysphoria treatment, including gender reassignment surgery and certain ancillary procedures.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 81410, 81411, 81413, 81414, 81439, 81443, 81493.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.
Last Published 05.01.2021
Effective Date: 09.01.2020 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.
Last Published 05.01.2021
Effective Date: 10.01.2019– This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 81440, 81460, 81465, 81479.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 0216U, 0217U, 81440, 81460, 81465, 81479.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses genitourinary pathogen nucleic acid detection panel testing to evaluate symptomatic women for vaginitis. Applicable Procedure Codes: 0068U, 81513, 81514, 87480, 87481, 87482, 87510, 87511, 87512, 87660, 87661, 87797, 87798, 87799, 87800, 87801.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses genitourinary pathogen nucleic acid detection panel testing to evaluate symptomatic women for vaginitis. Applicable Procedure Codes: 0068U, 81513, 81514, 87480, 87481, 87482, 87510, 87511, 87512, 87660, 87661, 87797, 87798, 87799, 87800, 87801.
Last Published 02.15.2021
Effective Date: 10.01.2020 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses glaucoma drainage devices/stents and canaloplasty. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 66174, 66175, 66179, 66180, 66183, 66184, 66185, L8612.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses glaucoma drainage devices/stents and canaloplasty. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 66174, 66175, 66179, 66180, 66183, 66184, 66185, L8612.
Last Published 05.01.2021
Effective Date: 06.01.2020 – This policy addresses glaucoma drainage devices/stents and canaloplasty. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 66174, 66175, 66179, 66180, 66183, 66184, 66185, L8612.
Last Published 06.01.2021
Effective Date: 02.01.2021 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products. Applicable Procedure Codes: J1950, J3315, J3316, J9155, J9202, J9217, J9225, J9226.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Last Published 05.01.2021
Effective Date: 08.01.2019 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Last Published 05.01.2021
Effective Date: 04.01.2020 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Last Published 05.01.2021
Effective Date: 12.01.2019 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.
Last Published 05.01.2021
Effective Date: 07.01.2019 – This policy addresses hepatitis screening. Applicable Procedure Codes: 81596, 86704, 86705, 86706, 86707, 86708, 86709, 86803, 86804, 87340, 87341, 87350, 87902, 87912, G0472, G0499.
Last Published 05.01.2021
Effective Date: 10.14.2020 – This policy addresses hepatitis screening. Applicable Procedure Codes: 81596, 86704, 86705, 86706, 86707, 86708, 86709, 86803, 86804, 87340, 87341, 87350, 87902, 87912, G0472, G0499.
Last Published 05.01.2021
Effective Date: 10.14.2020 – This policy addresses hepatitis screening. Applicable Procedure Codes: 86704, 86705, 86706, 86707, 86708, 86709, 86803, 86804, 87340, 87341, 87350, 87902, 87912, G0472, G0499.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of C1 esterace inhibitors (human), C1 esterace inhibitors (recombinant), and plasma kallikrein inhibitors (human) for the treatment and prophlaxis of hereditary angioedema (HAE). Applicable Procedure Codes: J0596, J0597, J0598, J1290.
Last Published 05.01.2021
Effective Date: 11.01.2019 – This policy addresses high-frequency chest wall compression (HFCWC). Applicable Procedure Codes: A7025, A7026, E0483.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses home health care services.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses home health care services.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Last Published 05.01.2021
Effective Date: 04.01.2020 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Last Published 06.01.2021
Effective Date: 06.01.2020 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Last Published 05.01.2021
Effective Date: 06.01.2020 – This policy addresses hospice and concurrent care services. Applicable Procedure Codes: T2042, T2043, T2044, T2045.
Last Published 05.01.2021
Effective Date: 06.01.2020 – This policy addresses hospice and concurrent care services. Applicable Procedure Codes: T2042, T2043, T2044, T2045.
Last Published 06.01.2021
Effective Date: 12.01.2020 – This policy addresses the use of Ilaris® (canakinumab) for the treatment of cryopyrin-associated periodic syndromes (CAPS), tumor necrosis factor (TNF) receptor-associated periodic syndrome (TRAPS), hyperimmunoglobulin D (Hyper-IgD) syndrome (HIDS)/mevalonate kinase deficiency (MKD), familial mediterranean fever (FMF), Still’s disease, and systemic juvenile idiopathic arthritis (SJIA). Applicable Procedure Code: J0638.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses the use of provider-administered Ilumya™ (tildrakizumab-asmn) for the treatment of moderate to severe plaque psoriasis. Applicable Procedure Code: J3245.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, J1459, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of malignant tumors. Applicable Procedure Codes: 37243, 79445, S2095.
Last Published 05.01.2021
Effective Date: 04.01.2020 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of malignant tumors. Applicable Procedure Codes: 37243, 79445, S2095.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses implanted electrical stimulators for spinal cord. Applicable Procedure Codes: 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses implanted electrical stimulators for spinal cord. Applicable Procedure Codes: 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses implanted electrical stimulator for spinal cord. Applicable Procedure Codes: 63650, 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.
Last Published 06.01.2021
Effective Date: 02.01.2021 – This policy addresses the use of infliximab products, including Avsola™ (infliximab-axxq), Inflectra® (infliximab-dyyb), Remicade® (infliximab), and Renflexis® (infliximab-abda). Applicable Procedure Codes: J1745, Q5103, Q5104, Q5109, Q5121.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses the use of inhaled nitric oxide (iNO) for treating term or near-term infants with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN). Applicable Procedure Code: 94799.
Last Published 05.01.2021
Effective Date: 03.01.2020 – This policy addresses the use of intensity-modulated radiation therapy (IMRT). Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of intensity-modulated radiation therapy (IMRT). Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of intensity-modulated radiation therapy (IMRT). Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 05.01.2021
Effective Date: 06.01.2019 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.
Last Published 05.01.2021
Effective Date: 06.01.2019 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.
Last Published 05.01.2021
Effective Date: 06.01.2019 – This policy addresses intrauterine fetal surgery. Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses intrauterine fetal surgery. Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Last Published 05.01.2021
Effective Date: 08.01.2020 – This policy addresses intrauterine fetal surgery. Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of intravenous enzyme replacement drug products for the treatment of Gaucher disease, including Cerezyme® (imiglucerase), Elelyso® (taliglucerase), and VPRIV® (velaglucerase). Applicable Procedure Codes: J1786, J3060, J3385.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses the use of intravenous iron replacement therapy with Feraheme® (ferumoxytol), Injectafer® (ferric carboxymaltose), and Monoferric® (ferric derisomaltose) for the treatment of iron deficiency anemia (IDA) with and without chronic kidney disease (CKD). Applicable Procedure Codes: J1437, J1439, Q0138.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of Ketalar® (ketamine) for anesthesia purposes and Spravato® (esketamine) for the treatment of treatment-resistant depression (TRD) and major depressive disorder (MDD). Applicable Procedure Codes: J3490, S0013.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.
Last Published 06.01.2021
Effective Date: 11.01.2020 – This policy addresses the use of Krystexxa® (pegloticase) for treatment of chronic gout refractory to conventional therapy. Applicable Procedure Code: J2507.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 64999.
Last Published 05.01.2021
Effective Date: 07.01.2020 – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 64999.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Lemtrada (alemtuzumab) for treatment of relapsing forms of multiple sclerosis. Applicable Procedure Code: J0202.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 17106, 17107, 17108, 17380.
Last Published 05.01.2021
Effective Date: 11.01.2020 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 17106, 17107, 17108, 17380.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.
Last Published 05.01.2021
Effective Date: 11.01.2020 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses lower extremity vascular angiography and endovascular revascularization procedures. Applicable Procedure Codes: 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235, 75710, 75716.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses lower extremity vascular angiography and endovascular revascularization procedures. Applicable Procedure Codes: 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235, 75710, 75716.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses lower extremity vascular angiography for evaluating arterial disease of the lower extremity. Applicable Procedure Codes: 75710, 75716.
Last Published 06.01.2021
Effective Date: 12.01.2020 – This policy addresses the use of Luxturna® (voretigene neparvovec-rzyl) for the treatment of inherited retinal dystrophies (IRD) caused by mutations in the retinal pigment epithelium-specific protein 65kDa (RPE65) gene. Applicable Procedure Code: J3398.
Last Published 05.01.2021
Effective Date: 05.01.2019 – This policy addresses implantable miniature telescope (IMT), conjunctival incision with posterior extrascleral placement of a pharmacologic agent, epiretinal radiation therapy, and laser photocoagulation. Applicable Procedure Codes: 0308T, 67036, 67299, 92499.
Last Published 05.01.2021
Effective Date: 06.01.2020 – This policy addresses implantable miniature telescope (IMT), conjunctival incision with posterior extrascleral placement of a pharmacologic agent, epiretinal radiation therapy, and laser photocoagulation. Applicable Procedure Codes: 0308T, 67036, 67299, 92499.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.
Last Published 05.01.2021
Effective Date: 07.01.2020 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98940, 98941, 98942, 98943, S8990.
Last Published 05.01.2021
Effective Date: 05.01.2019 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.
Last Published 05.01.2021
Effective Date: 06.01.2020 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.
Last Published 05.01.2021
Effective Date: 08.01.2020 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.
Last Published 05.01.2021
Effective Date: 10.01.2019 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD). Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43499, 43999.
Last Published 05.01.2021
Effective Date: 10.01.2019 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD). Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43499, 43999.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD) and the Per Oral Endoscopic Myotomy (POEM) procedure for achalasia or diffuse esophageal spasm. Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43499, 43999.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.
Last Published 05.01.2021
Effective Date: 06.01.2020 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.
Last Published 05.01.2021
Effective Date: 03.01.2020 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.
Last Published 05.01.2021
Effective Date: 09.01.2019 – This policy addresses sural or other nerve grafts to restore erectile function during radical prostatectomy. Applicable Procedure Codes: 55899, 64999.
Last Published 05.01.2021
Effective Date: 09.01.2019 – This policy addresses sural or other nerve grafts to restore erectile function during radical prostatectomy. Applicable Procedure Codes: 55899, 64999.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy. Applicable Procedure Codes: 55899, 64999.
Last Published 05.01.2021
Effective Date: 09.01.2019 – This policy addresses nerve conduction studies and other neurophysiological testing.
Last Published 05.01.2021
Effective Date: 09.01.2019 – This policy addresses nerve conduction studies and other neurophysiological testing.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses nerve conduction studies and other neurophysiological testing.
Last Published 05.01.2021
Effective Date: 06.01.2019 – This policy addresses neuropsychological testing and computerized cognitive testing under the medical benefit. Applicable Procedure Codes: 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146.
Last Published 05.01.2021
Effective Date: 08.01.2020 – This policy addresses neuropsychological testing and computerized cognitive testing under the medical benefit. Applicable Procedure Codes: 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses neuropsychological testing and computerized cognitive testing under the medical benefit. Applicable Procedure Codes: 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses non-medical transportation. Applicable Procedure Codes: T2002, T2003.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of Nplate® (romiplostim) for the treatment of chronic immune thrombocytopenic purpura (ITP). Applicable Procedure Code: J2796.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses observation services in a hospital setting.
Last Published 05.07.2021
Effective Date: 05.01.2021 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0466T, 0467T, 0468T, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, E0485, E0486, K1001, L8679, L8680, L8686, S2080, S2900.
Last Published 05.07.2021
Effective Date: 05.01.2021 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0466T, 0467T, 0468T, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, E0485, E0486, L8679, L8680, L8686, S2080.
Last Published 05.07.2021
Effective Date: 05.01.2021 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0466T, 0467T, 0468T, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, E0485, E0486, K1001, L8679, L8680, L8686, S2080, S2900.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses occipital neuralgia and headache treatments, including injection of local anesthetics and/or steroids used as occipital nerve blocks, neurostimulation or electrical stimulation, occipital neurectomy, radiofrequency ablation (thermal or pulsed) or denervation, rhizotomy, and surgical nerve decompression. Applicable Procedure Codes: 62281, 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64633, 64634, 64722, 64744, 64771, 64999, L8679, L8680, L8685.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses occipital neuralgia and headache treatments, including injection of local anesthetics and/or steroids used as occipital nerve blocks, neurostimulation or electrical stimulation, occipital neurectomy, radiofrequency ablation (thermal or pulsed) or denervation, rhizotomy, and surgical nerve decompression. Applicable Procedure Codes: 62281, 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64633, 64634, 64722, 64744, 64771, 64999, L8679, L8680, L8685.
Last Published 05.01.2021
Effective Date: 08.01.2020 – This policy addresses occipital neuralgia and headache treatments, including injection of local anesthetics and/or steroids used as occipital nerve blocks, neurostimulation or electrical stimulation, occipital neurectomy, radiofrequency ablation (thermal or pulsed) or denervation, rhizotomy, and surgical nerve decompression. Applicable Procedure Codes: 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64633, 64634, 64722, 64744, 64771, 64999, L8679, L8680, L8685.
Last Published 03.08.2021
Effective Date: 10.01.2020 – This policy addresses the use of Ocrevus® (ocrelizumab) for the treatment of multiple sclerosis. Applicable Procedure Code: J2350.
Last Published 06.01.2021
Effective Date: 12.01.2020 – This policy addresses the use of Ocrevus® (ocrelizumab) for the treatment of multiple sclerosis. Applicable Procedure Code: J2350.
Last Published 06.01.2021
Effective Date: 11.01.2020 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.
Last Published 05.01.2021
Effective Date: 02.01.2020 – This policy addresses multiple services/procedures.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses multiple services/procedures.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses multiple services/procedures.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses multiple services/procedures.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Codes: J0640, J0641, J0642, J9035, J9198, J9199, J9201, J9310, J9312, J9355, J9356, Q5107, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119.
Last Published 06.01.2021
Effective Date: 09.01.2020 – This policy addresses the use of Onpattro® (patisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedures Code: J0222.
Last Published 06.01.2021
Effective Date: 03.01.2021 – This policy addresses the use of vascular endothelial growth factor (VEGF) inhibitors. Applicable Procedure Codes: J0178, J0179, J2503, J2778, J9035, Q5107, Q5118.
Last Published 05.01.2021
Effective Date: 06.01.2019 – This policy addresses oral and enteral nutrition. Applicable Procedure Codes: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, S9433, S9434, S9435.
Last Published 05.01.2021
Effective Date: 06.01.2020 – This policy addresses oral and enteral nutrition. Applicable Procedure Codes: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, S9433, S9434, S9435.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Orencia® (abatacept) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, psoriatic arthritis, chronic graft-versus-host disease, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J0129.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses orthognathic (jaw) surgery.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses orthognathic (jaw) surgery.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses orthognathic (jaw) surgery.
Last Published 05.01.2021
Effective Date: 01.01.2019 – This policy addresses osteochondral autograft and allograft transplantation and minced articular cartilage repair (allograft or autograft). Applicable Procedure Codes: 27415, 27416, 28446, 29866, 29867.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses occupational therapy and physical therapy evaluation and treatment services.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses occupational therapy and physical therapy evaluation and treatment services.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses outpatient speech, occupational, and physical therapy services.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses sites of care for outpatient speech, occupational, and physical therapy services.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the medical necessity of certain elective procedures when performed in a hospital outpatient department.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the medical necessity of certain elective procedures when performed in a hospital outpatient department.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the medical necessity of certain planned surgical procedures when performed in a hospital outpatient department.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Oxlumo™ (Lumasiran) for the treatment of primary hyperoxaluria type 1 (PH1). Applicable Procedures Codes: C9074, J3490, J3590.
Last Published 05.01.2021
Effective Date: 02.01.2020 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.
Last Published 05.01.2021
Effective Date: 04.01.2020 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.
Last Published 05.01.2021
Effective Date: 11.01.2020 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.
Last Published 05.01.2021
Effective Date: 07.01.2019 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Last Published 05.01.2021
Effective Date: 07.01.2020 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of pharmacogenetic multi-gene panel testing for genetic polymorphisms. Applicable Procedure Codes: 0029U, 0078U, 0173U, 0175U, 81479.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of pharmacogenetic multi-gene panel testing for genetic polymorphisms. Applicable Procedure Codes: 0029U, 0078U, 0173U, 0175U, 81479.
Last Published 05.01.2021
Effective Date: 10.01.2019 – This policy addresses the use of cranial orthotic devices for treating infants with plagiocephaly and craniosynostosis. Applicable Procedure Codes: 21175, D5924, L0112, L0113, S1040.
Last Published 05.01.2021
Effective Date: 10.01.2019 – This policy addresses the use of cranial orthotic devices for treating infants with plagiocephaly and craniosynostosis. Applicable Procedure Codes: 21175, D5924, L0112, L0113, S1040.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses the use of cranial orthotic devices for treating infants following craniosynostosis surgery or for nonsynostotic (nonfusion) deformational or positional plagiocephaly. Applicable Procedure Codes: 21175, D5924, L0112, L0113, S1040.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Last Published 05.01.2021
Effective Date: 07.01.2019 – This policy addresses preimplantation genetic testing (PGT). Applicable Procedure Codes: 81228, 81229, 81479.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses preimplantation genetic testing (PGT). Applicable Procedure Codes: 81228, 81229, 81479.
Last Published 05.01.2021
Effective Date: 08.01.2020 – This policy addresses private duty nursing (PDN) services. Applicable Procedure Codes: S9123, S9124.
Last Published 05.01.2021
Effective Date: 10.01.2019 – This policy addresses private duty nursing (PDN) services. Applicable Procedure Code: S9123, S9124, T1000, T1001, T1002, T1003, T1030, T1031.
Last Published 05.01.2021
Effective Date: 03.01.2021 – This policy addresses private duty nursing (PDN) services. Applicable Procedure Codes: T1000, T1002, T1003.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses private duty nursing (PDN) services. Applicable Procedure Code: S9123, S9124, T1000, T1001, T1002, T1003, T1030, T1031.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, 0481T, G0460, M0076, P9020, S9055.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, 0481T, G0460, M0076, P9020, S9055.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, 0481T, G0460, M0076, P9020, S9055.
Last Published 05.01.2021
Effective Date: 02.01.2020 – This policy addresses prosthetic devices, specialized/computerized/myoelectric limbs, and includes applicable procedure codes for breast prosthesis, ear/eye/nose/facial prosthesis, lower and upper limb prosthetics, additions to upper extremity, prosthetic socks, and repairs and replacements.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses prosthetic devices, specialized/computerized/myoelectric limbs, and includes applicable procedure codes for breast prosthesis, ear/eye/nose/facial prosthesis, lower and upper limb prosthetics, additions to upper extremity, prosthetic socks, and repairs and replacements.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses prosthetic devices, specialized/computerized/myoelectric limbs, and includes applicable procedure codes for breast prosthesis, ear/eye/nose/facial prosthesis, lower and upper limb prosthetics, additions to upper extremity, prosthetic socks, and repairs and replacements.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 05.01.2021
Effective Date: 01.01.2019 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 05.01.2021
Effective Date: 12.16.2019 – This policy addresses hospital outpatient facility medication infusion services, including the use of Actemra®, Entyvio®, Ilumya™, Inflectra™, Orencia®, Remicade®, Renflexis™, and Simponi Aria®.
Last Published 05.01.2021
Effective Date: 12.16.2019 – This policy addresses hospital outpatient facility medication infusion services, including the use of Actemra®, Entyvio®, Ilumya™, Inflectra™, Orencia®, Remicade®, Renflexis™, and Simponi Aria®.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses hospital outpatient facility medication infusion services, including the use of Actemra®, Entyvio®, Ilumya™, Inflectra™, Orencia®, Remicade®, Renflexis™, and Simponi Aria®.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Radicava® (edaravone) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses Reblozyl® (luspatercept-aamt) for the treatment of anemia in adult patients with beta thalassemia and symptomatic anemia in patients with myelodysplastic sydromes or myelodysplastic/myeloproliferative neoplasms. Applicable Procedure Code: J0896.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of repository corticotropin injection (Acthar® Gel) for the treatment of infantile spasm, opsoclonus-myoclonus syndrome, and acute exacerbation of multiple sclerosis (MS). Applicable Procedure Code: J0800.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of repository corticotropin injection (Acthar® Gel) for the treatment of infantile spasm, opsoclonus-myoclonus syndrome, and acute exacerbation of multiple sclerosis (MS). Applicable Procedure Code: J0800.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of interleukin-5 (IL-5) antagonists, including Cinqair® (reslizumab), Fasenra® (benralizumab), and Nucala® (mepolizumab). Applicable Procedure Codes: J0517, J2182, J2786.
Last Published 06.14.2021
Effective Date: 11.01.2020 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 05.01.2021
Effective Date: 12.01.2019 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, and septal dermatoplasty. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30560, 30620.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, and septal dermatoplasty. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30560, 30620.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, septal dermatoplasty, and nasal polypectomy. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30560, 30620, 31237.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of Riabni™ (rituximab-arrx), Rituxan® (rituximab), Ruxience® (rituximab-pvvr), and Truxima® (rituximab-abbs). Applicable Procedure Codes: J9311, J9312, Q5115, Q5119.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses Scenesse® (afamelanotide) for the treatment of erythropoietic protoporphyria (EPP). Applicable Procedure Code: J7352.
Last Published 05.01.2021
Effective Date: 09.01.2019 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses shoulder replacement surgery (arthroplasty and hemiarthroplasty). Applicable Procedure Codes: 23470, 23472, 23473, 23474.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses shoulder replacement surgery (arthroplasty and hemiarthroplasty). Applicable Procedure Codes: 23470, 23472, 23473, 23474.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses shoulder replacement surgery (arthroplasty and hemiarthroplasty). Applicable Procedure Codes: 23470, 23472, 23473, 23474.
Last Published 06.01.2021
Effective Date: 03.01.2021 – This policy addresses Simponi Aria® (golimumab) injection for intravenous infusion for the treatment of ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis. Applicable Procedure Code: J1602.
Last Published 05.01.2021
Effective Date: 07.01.2019 – This policy addresses skilled care and custodial care services. Applicable Procedure Codes: 99509, S5100, S5101, S5102, S5105, S5120, S5121, S5125, S5126, S5130, S5131, S5135, S5136, S5140, S5141, S5150, S5151, S5170, S5175, S9125, T1005, T1019, T1020.
Last Published 05.01.2021
Effective Date: 07.01.2020 – This policy addresses skilled care and custodial care services. Applicable Procedure Codes: 99509, S5100, S5101, S5102, S5105, S5120, S5121, S5125, S5126, S5130, S5131, S5135, S5136, S5140, S5141, S5150, S5151, S5170, S5175, S9125, T1005, T1019, T1020.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses skin and soft tissue substitutes.
Last Published 05.01.2021
Effective Date: 10.01.2019 – This policy addresses skin and soft tissue substitutes.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses skin and soft tissue substitutes.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses intra-articular injections of sodium hyaluronate. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.
Last Published 06.01.2021
Effective Date: 12.01.2020 – This policy addresses the use of somatostatin analogs, including Sandostatin® (octreotide acetate), Sandostatin® LAR (octreotide acetate LAR), Signifor® (pasireotide diaspartate), Signifor® LAR (pasireotide), and Somatuline® Depot (lanreotide). Applicable Procedure Codes: J1930, J2353, J2354, J2502.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses speech and language therapy (speech-language pathology services) for the treatment of disorders of speech, language, voice, communication, and auditory processing. Applicable Procedure Codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92609, 92610, 92626, 92627, 92630, 92633, 96105, S9152, V5362, V5363, V5364.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses speech and language therapy (speech-language pathology services) for the treatment of disorders of speech, language, voice, communication, and auditory processing. Applicable Procedure Codes: 70371, 92507, 92508, 92521, 92522, 92523, 92524, 92526, 96105, S9152, V5362, V5363.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses speech and language therapy (speech-language pathology services) for the treatment of disorders of speech, language, voice, communication, and auditory processing. Applicable Procedure Codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92609, 92610, 92626, 92627, 92630, 92633, 96105, S9152, V5362, V5363, V5364.
Last Published 05.01.2021
Effective Date: 07.01.2019 – This policy addresses spinal and paraspinal ultrasonography. Applicable Procedure Codes: 76536, 76800, 76856, 76857, 76881, 76882.
Last Published 05.03.2021
Effective Date: 07.01.2019 – This policy addresses spinal and paraspinal ultrasonography. Applicable Procedure Codes: 76536, 76800, 76856, 76857, 76881, 76882.
Last Published 05.01.2021
Effective Date: 11.01.2020 – This policy addresses spinal and paraspinal ultrasonography. Applicable Procedure Code: 76800.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of Spinraza® (nusinersen) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J2326.
Last Published 06.01.2021
Effective Date: 12.01.2020 – This policy addresses the use of Spinraza® (nusinersen) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J2326.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses standing systems and gait trainers for individuals who are non-ambulatory. Applicable Procedure Codes: E0637, E0638, E0641, E0642, E8000, E8001, E8002.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses standing systems and pediatric gait trainers. Applicable Procedure Codes: E0637, E0638, E0641, E0642, E8000, E8001, E8002.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses standing systems and pediatric gait trainers. Applicable Procedure Codes: E0637, E0638, E0641, E0642, E8000, E8001, E8002.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Stelara® (ustekinumab) for the treatment of Crohn’s disease, plaque psoriasis, psoriatic arthritis, and ulcerative colitis. Applicable Procedure Codes: J3357, J3358.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses the use of compounded implantable drug pellets. Applicable Procedure Codes: 11981, 11982, 11983, J3490, J7999.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses surgery of the hip and femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 29860, 29861, 29862, 29863, 29914, 29915, 29916, 29999, S2118.
Last Published 05.01.2021
Effective Date: 09.01.2019 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 36465, 36466, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37780, 37799.
Last Published 05.01.2021
Effective Date: 03.01.2020 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 36465, 36466, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37780, 37799.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses varicose vein ablative and stripping procedures, ligation procedures, and ambulatory phlebectomy. Applicable Procedure Codes: 36465, 36466, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses surgical treatment for spine pain.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses surgical treatment for spine pain.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses surgical treatment for spine pain.
Last Published 06.01.2021
Effective Date: 12.01.2020 – This policy addresses the use of Synagis® (palivizumab) to prevent serious respiratory syncytial virus disease (RSV) in high risk infants and young children. Applicable Procedure Code: 90378.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Code: J3241.
Last Published 06.01.2021
Effective Date: 02.01.2021 – This policy addresses the use of injectable testosterone and testosterone pellets for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone. Applicable Procedure Codes: 11980, J1071, J3121, J3145, S0189.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses thermography, including digital infrared thermal imaging, temperature gradient studies, and magnetic resonance (MR) thermography. Applicable Procedure Codes: 76498, 93740.
Last Published 05.01.2021
Effective Date: 05.01.2020 – This policy addresses thermography, including digital infrared thermal imaging, temperature gradient studies, and magnetic resonance (MR) thermography. Applicable Procedure Codes: 76498, 93740.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses thermography, including digital infrared thermal imaging, temperature gradient studies, and magnetic resonance (MR) thermography. Applicable Procedure Codes: 76498, 93740.
Last Published 05.01.2021
Effective Date: 03.01.2020 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899.
Last Published 05.01.2021
Effective Date: 09.01.2019 – This policy addresses the SynCardia™ temporary Total Artificial Heart. Applicable Procedure Codes: 33927, 33928.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses the SynCardia™ temporary Total Artificial Heart. Applicable Procedure Codes: 33927, 33928.
Last Published 05.01.2021
Effective Date: 03.01.2020 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral, tricuspid) procedures, including valve-in-valve procedures and transcatheter cerebral protection devices. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33999, 93799.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral, tricuspid) procedures, including valve-in-valve procedures and transcatheter cerebral protection devices. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0569T, 0570T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33999, 93799.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses transcatheter heart valve (aortic, mitral, pulmonary) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33999, 93799.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.
Last Published 05.01.2021
Effective Date: 04.01.2020 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.
Last Published 05.01.2021
Effective Date: 07.01.2019 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.
Last Published 06.01.2021
Effective Date: 06.01.2020 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Trogarzo® (ibalizumab-uiyk) for the treatment of multi-drug resistant human immunodeficiency virus (HIV). Applicable Procedure Code: J1746.
Last Published 06.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Tysabri® (natalizumab) for the treatment of relapsing forms of multiple sclerosis and Crohn's disease. Applicable Procedure Code: J2323.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Last Published 05.01.2021
Effective Date: 07.01.2020 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses Uplizna® (inebilizumab-cdon) for the treatment of neuromyelitis optica spectrum disorder (NMOSD). Applicable Procedure Code: J1823.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 64553, 64568, 64570, E0770, E1399, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 64553, 64568, 64570, E0770, E1399, K1016, K1017, K1020, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Last Published 05.01.2021
Effective Date: 05.01.2019 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus nerve stimulation. Applicable Procedure Codes: 61885, 64553, 64568, 64570, E0770, E1399, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Code: 22899.
Last Published 05.01.2021
Effective Date: 04.01.2021 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Code: 22899.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Code: 22899.
Last Published 04.01.2021
Effective Date: 04.01.2021 – This policy addresses Viltepso® (viltolarsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1427.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses Viltepso® (viltolarsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1427.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Last Published 05.01.2021
Effective Date: 12.01.2020 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Last Published 05.01.2021
Effective Date: 01.01.2020 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 92065, 92499.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 92065, 92499.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses the use of Vyepti™ (Eptinezumab) for the treatment of chronic and episodic migraine. Applicable Procedure Code: J3032.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of Vyondys 53™ (golodirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1429.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Vyondys 53™ (golodirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1429.
Last Published 05.01.2021
Effective Date: 01.01.2021 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 97610, A6000, E0231, E0232.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 97610, A6000, E0231, E0232.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses the use of white blood cell colony stimulating factors (CSFs), including the drug products Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nyvepria, Udenyca, Zarxio, and Ziextenzo. Applicable Procedure Codes: J1442, J1447, J2505, J2820, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122.
Last Published 05.01.2021
Effective Date: 10.01.2020 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0012U, 0013U, 0014U, 0036U, 0094U, 0212U, 0213U, 0214U, 0215U, 81415, 81416, 81417, 81425, 81426, 81427.
Last Published 05.01.2021
Effective Date: 02.01.2021 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0012U, 0013U, 0014U, 0036U, 0094U, 0212U, 0213U, 0214U, 0215U, 81415, 81416, 81417, 81425, 81426, 81427.
Last Published 06.01.2021
Effective Date: 04.01.2021 – This policy addresses the use of Xiaflex® (collagenase clostridium histolyticum) for the treatment of Dupuytren’s contracture and Peyronie’s disease. Applicable Procedure Codes: 20527, 26341, J0775.
Last Published 06.01.2021
Effective Date: 03.01.2021 – This policy addresses the use of Xolair® (omalizumab) for subcutaneous use for the treatment of moderate to severe persistent asthma, chronic urticaria, and nasal polyps. Applicable Procedure Code: J2357.
Last Published 03.01.2021
Effective Date: 03.01.2021 – This policy addresses the use of Zolgensma® (onasemnogene abeparvovec-xioi) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J3399.
Last Published 06.01.2021
Effective Date: 02.01.2021 – This policy addresses the use of Zolgensma® (onasemnogene abeparvovec-xioi) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J3399.
Last Published 06.01.2021
Effective Date: 12.01.2020 – This policy addresses the use of Zulresso™ (brexanolone) for the treatment of postpartum depression (PPD) in adults. Applicable Procedure Code: J1632.
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