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Community Plan Medical & Drug Policies and Coverage Determination Guidelines

The Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, Utilization Review Guidelines and corresponding update bulletins for UnitedHealthcare Community Plan are listed below.

Click the "+" sign 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.

01/01/2021 – Community Plan Medical Policy Update Bulletin: January 2021

Last Published 01.01.2021

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).

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11/01/2020 – Community Plan Medical Policy Update Bulletin: November 2020

Last Published 11.01.2020

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).

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12/01/2020 – Community Plan Medical Policy Update Bulletin: December 2020

Last Published 12.01.2020

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).

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Community Plan Medical Policy Update Bulletin Archive

Last Published 01.01.2021

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Current Policies & Guidelines

For Kentucky, click here to view the Medical & Drug Policies and Coverage Determination Guidelines.

For Louisiana, click here to view MCG criteria for the top Outpatient procedures and Admission diagnoses.

Community Plan Medical & Drug Policies and Coverage Determination Guidelines Terms and Conditions

Please read the terms and conditions below carefully.

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 MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines 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 MCG™ Care Guidelines are proprietary to MCG™ 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:

  1. State/Federal Guidelines and Contract Requirements
  2. UnitedHealthcare Community Plan Medical & Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines
  3. MCG™ Care Guidelines

By clicking "I Agree," you agree to be bound by the terms and conditions expressed herein, in addition to our Site Use Agreement.

17-Alpha-Hydroxyprogesterone Caproate (Makena® and 17P) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

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.

Ablative Treatment for Spinal Pain (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2020 – 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.

Ablative Treatment for Spinal Pain (for New Jersey Only) – Community Plan Medical Policy

Last Published 02.01.2020

Effective Date: 10.01.2019 – This policy addresses thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 64633, 64634, 64635, 64636, 64999.

Ablative Treatment for Spinal Pain (for Tennessee Only) – Community Plan Medical Policy

Last Published 02.01.2020

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.

Ablative Treatment for Spinal Pain – Community Plan Medical Policy

Last Published 02.01.2020

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.

Abnormal Uterine Bleeding and Uterine Fibroids (for Louisiana Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 09.01.2020 – 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.

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Abnormal Uterine Bleeding and Uterine Fibroids (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

Abnormal Uterine Bleeding and Uterine Fibroids (for New Jersey Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 05.01.2020 – 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.

Abnormal Uterine Bleeding and Uterine Fibroids (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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.

Abnormal Uterine Bleeding and Uterine Fibroids – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – 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.

Actemra® (Tocilizumab) Injection for Intravenous Infusion (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 05.01.2020

Effective Date: 01.01.2020 – 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, and cytokine release syndrome. Applicable Procedure Code: J3262.

Actemra® (Tocilizumab) Injection for Intravenous Infusion – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – 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.

Adakveo® (Crizanlizumab-Tmca) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses the use of Adakveo® (crizanlizumab-tmca) to reduce the frequency of vasoocclusive crises in patients with sickle cell disease. Applicable Procedure Codes: C9399, J3490, J3590.

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Adakveo® (Crizanlizumab-Tmca) – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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.

Alpha1-Proteinase Inhibitors (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 11.01.2019 (state-specific policy version created 12.01.2020; no change to policy guidelines) – 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.

Alpha1-Proteinase Inhibitors – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

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.

Ambulance Services (for Florida Only) – Community Plan Coverage Determination Guideline

Last Published 09.01.2020

Effective Date: 09.01.2020 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.

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,

Ambulance Services (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 07.01.2020

Effective Date: 07.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – 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.

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Ambulance Services (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 07.01.2020

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.

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Ambulance Services (for New Jersey Only) – Community Plan Coverage Determination Guideline

Last Published 07.01.2020

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.

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Ambulance Services (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.

Ambulance Services – Community Plan Coverage Determination Guideline

Last Published 09.01.2020

Effective Date: 09.01.2020 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.

Apheresis (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2020 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.

Apheresis (for New Jersey Only) – Community Plan Medical Policy

Last Published 02.01.2020

Effective Date: 02.01.2019 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.

Apheresis (for Tennessee Only) – Community Plan Medical Policy

Last Published 02.01.2020

Effective Date: 12.01.2019 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.

Apheresis – Community Plan Medical Policy

Last Published 02.01.2020

Effective Date: 12.01.2019 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.

Articular Cartilage Defect Repairs (for Louisiana Only) – Community Plan Medical Policy

Last Published 05.01.2020

Effective Date: 05.01.2020 – 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.

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Articular Cartilage Defect Repairs (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2020

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.

Articular Cartilage Defect Repairs – Community Plan Medical Policy

Last Published 05.01.2020

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.

Athletic Pubalgia Surgery (for Louisiana Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 06.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.

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Athletic Pubalgia Surgery (for Nebraska Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 06.01.2019 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.

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Athletic Pubalgia Surgery (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.

Athletic Pubalgia Surgery – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.

Attended Polysomnography for Evaluation of Sleep Disorders (for New Jersey Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 04.01.2020 – 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.

Attended Polysomnography for Evaluation of Sleep Disorders – Community Plan Medical Policy

Last Published 12.11.2020

Effective Date: 05.01.2020 – 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.

Autologous Cellular Therapy for Certain Indications (for Florida Only) – Community Plan Medical Policy

Last Published 10.05.2020

Effective Date: 10.01.2020 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 27599.

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Autologous Cellular Therapy for Certain Indications (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses autologous cellular therapy. Applicable Procedure Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 27599.

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Autologous Cellular Therapy for Certain Indications – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 10.01.2020 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 27599.

Autologous Chondrocyte Transplantation in the Knee (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2020

Effective Date: 01.01.2019 – This policy addresses autologous chondrocyte transplantation (ACT). Applicable Procedure Codes: 27412, J7330, S2112.

Balloon Sinus Ostial Dilation (for Florida Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298, 31299.

Balloon Sinus Ostial Dilation (for Louisiana Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298.

Balloon Sinus Ostial Dilation (for Nebraska Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 01.01.2020 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298.

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Balloon Sinus Ostial Dilation (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2020

Effective Date: 01.01.2020 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298.

Balloon Sinus Ostial Dilation (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298, 31299.

Balloon Sinus Ostial Dilation – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298, 31299.

Bariatric Surgery (for Nebraska Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 10.01.2020 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, gastric sleeve procedure, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.

0312T, 0313T, 0314T, 0315T, 0316T, 0317T, 43644, 43645, 43647, 43648, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43860, 43865, 43881, 43882, 43886, 43887, 43888, 43999, 64590, 64595,

Bariatric Surgery (for New Jersey Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 10.01.2019 – This policy addresses bariatric surgical procedures, including gastric bypass, adjustable gastric banding, gastric sleeve procedure (gastrectomy), vertical banded gastroplasty, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.

0312T, 0313T, 0314T, 0315T, 0316T, 0317T, 43644, 43645, 43647, 43648, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43860, 43865, 43881, 43882, 43886, 43887, 43888, 43999, 64590, 64595,

Bariatric Surgery (for Tennessee Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, gastric sleeve procedure, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.

Bariatric Surgery – Community Plan Medical Policy

Last Published 01.01.2021

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.

Benlysta® (Belimumab) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses the use of Benlysta® (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE). Applicable Procedure Code: J0490.

Benlysta® (Belimumab) – Community Plan Medical Benefit Drug Policy

Last Published 09.17.2020

Effective Date: 09.01.2020 – This policy addresses the use of Benlysta® (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE). Applicable Procedure Code: J0490.

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Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 07.01.2020

Effective Date: 04.01.2020 (state-specific policy version created 07.01.2020; no change to policy guidelines) – 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).

15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966,

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 08.01.2020

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).

15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966,

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair (for New Jersey Only) – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

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).

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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).

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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).

Bone or Soft Tissue Healing and Fusion Enhancement Products (for Florida Only) – Community Plan Medical Policy

Last Published 09.01.2020

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.

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Bone or Soft Tissue Healing and Fusion Enhancement Products (for Louisiana Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – 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.

Bone or Soft Tissue Healing and Fusion Enhancement Products (for Nebraska Only) – Community Plan Medical Policy

Last Published 09.01.2020

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.

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Bone or Soft Tissue Healing and Fusion Enhancement Products (for New Jersey Only) – Community Plan Medical Policy

Last Published 02.01.2020

Effective Date: 04.01.2019 – 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: 0232T, 20930, 20931, 20932, 20933, 20934, 22558, 22585, 22899, Q4100, Q4149, Q4186, Q4187.

Bone or Soft Tissue Healing and Fusion Enhancement Products (for Tennessee Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses bone or soft tissue healing and fusion enhancement products/systems. Applicable Procedure Codes: 20930, 20931, 20932, 20933, 20934, 22558, 22585, 22899.

Bone or Soft Tissue Healing and Fusion Enhancement Products – Community Plan Medical Policy

Last Published 09.01.2020

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.

Botulinum Toxins A and B (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 02.12.2020

Effective Date: 03.01.2019 – 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.

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Botulinum Toxins A and B – Community Plan Medical Benefit Drug Policy

Last Published 09.17.2020

Effective Date: 09.01.2020 – 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.

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Breast Imaging for Screening and Diagnosing Cancer (for Florida Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

Breast Imaging for Screening and Diagnosing Cancer (for Louisiana Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 05.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – 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.

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Breast Imaging for Screening and Diagnosing Cancer (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

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.

Breast Imaging for Screening and Diagnosing Cancer (for New Jersey Only) – Community Plan Medical Policy

Last Published 10.01.2020

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.

Breast Imaging for Screening and Diagnosing Cancer (for Tennessee Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

Breast Imaging for Screening and Diagnosing Cancer – Community Plan Medical Policy

Last Published 10.01.2020

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.

Breast Reconstruction Post Mastectomy (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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.

Breast Reconstruction Post Mastectomy (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

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.

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Breast Reconstruction Post Mastectomy (for New Jersey Only) – Community Plan Coverage Determination Guideline

Last Published 03.01.2020

Effective Date: 01.01.2020 – This policy addresses breast reconstruction post-mastectomy.

Breast Reconstruction Post Mastectomy (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 02.01.2020

Effective Date: 02.01.2020 – This policy addresses breast reconstruction post-mastectomy.

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

Breast Reconstruction Post Mastectomy and Poland Syndrome – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

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.

Breast Reduction Surgery (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 05.06.2020

Effective Date: 05.01.2020 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.

Breast Reduction Surgery (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 05.01.2020

Effective Date: 03.01.2020 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.

Breast Reduction Surgery (for New Jersey Only) – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.

Breast Reduction Surgery (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.

Breast Reduction Surgery – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.

Breast Repair/Reconstruction Not Following Mastectomy (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.

Breast Repair/Reconstruction Not Following Mastectomy (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

Effective Date: 11.01.2019 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.

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Breast Repair/Reconstruction Not Following Mastectomy (for New Jersey Only) – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

Effective Date: 11.01.2019 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.

Breast Repair/Reconstruction Not Following Mastectomy (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 02.12.2020

Effective Date: 12.01.2019 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.

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Breast Repair/Reconstruction Not Following Mastectomy – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.

Brineura® (Cerliponase Alfa) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses the use of Brineura® (cerliponase alfa) in pediatric patients with late infantile neuronal ceroid lipofuscinosis (LINCL). Applicable Procedure Code: J0567.

Brineura® (Cerliponase Alfa) (for Pennsylvania Only) – Community Plan Medical Benefit Drug Policy

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.

Brineura® (Cerliponase Alfa) – Community Plan Medical Benefit Drug Policy

Last Published 09.01.2020

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.

Bronchial Thermoplasty (for Louisiana Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.

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Bronchial Thermoplasty (for Nebraska Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 07.01.2019 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.

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Bronchial Thermoplasty (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.

Bronchial Thermoplasty – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.

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Buprenorphine (Probuphine® & Sublocade®) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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.

Buprenorphine (Probuphine® & Sublocade®) – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

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.

Cardiac Event Monitoring (for Louisiana Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

Cardiac Event Monitoring (for Nebraska Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 02.01.2020 – 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.

Cardiac Event Monitoring (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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, 93299, E0616, G2066.

Cardiac Event Monitoring (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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.

Cardiac Event Monitoring – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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.

Cardiovascular Disease Risk Tests (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2020 – 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, 0111T, 0126T, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.

Cardiovascular Disease Risk Tests (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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, 0111T, 0126T, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.

Cardiovascular Disease Risk Tests (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

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.

Cardiovascular Disease Risk Tests – Community Plan Medical Policy

Last Published 01.01.2021

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.

Carrier Testing for Genetic Diseases (for Louisiana Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 81412, 81443, 81479.

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Carrier Testing for Genetic Diseases (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 81412, 81443, 81479.

Carrier Testing for Genetic Diseases – Community Plan Medical Policy

Last Published 09.01.2020

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.

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Cell-Free Fetal DNA Testing (for Florida Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 09.01.2020 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0168U, 81420, 81422, 81479, 81507.

Cell-Free Fetal DNA Testing (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0168U, 81420, 81422, 81479, 81507.

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Cell-Free Fetal DNA Testing – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 09.01.2020 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0168U, 81420, 81422, 81479, 81507.

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Certified Nursing Assistant (CNA) or Home Health Aide for Adults Age 21 and Older (for Florida Only) – Community Plan Coverage Determination Guideline

Last Published 08.01.2020

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.

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Chelation Therapy for Non-Overload Conditions (for Florida Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.

Chelation Therapy for Non-Overload Conditions (for Louisiana Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.

Chelation Therapy for Non-Overload Conditions (for Nebraska Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 03.01.2019 – This policy addresses chelation therapy. Applicable Procedure Codes: J3490, M0300, S9355.

Chelation Therapy for Non-Overload Conditions (for New Jersey Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 03.01.2019 – This policy addresses chelation therapy. Applicable Procedure Codes: J3490, M0300, S9355.

Chelation Therapy for Non-Overload Conditions (for Tennessee Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.

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Chelation Therapy for Non-Overload Conditions – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.

Chemosensitivity and Chemoresistance Assays in Cancer (for Louisiana Only) – Community Plan Medical Policy

Last Published 03.10.2020

Effective Date: 07.01.2019 – This policy addresses chemosensitivity and chemoresistance assays in cancer. Applicable Procedure Codes: 0083U, 81535, 81536, 86849, 89240.

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Chemosensitivity and Chemoresistance Assays in Cancer (for Nebraska Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 01.01.2020 – This policy addresses chemosensitivity and chemoresistance assays in cancer. Applicable Procedure Codes: 0083U, 0564T, 81535, 81536, 86849, 89240.

Chemosensitivity and Chemoresistance Assays in Cancer (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses chemosensitivity and chemoresistance assays in cancer. Applicable Procedure Codes: 0083U, 0564T, 81535, 81536, 86849, 89240.

Chemosensitivity and Chemoresistance Assays in Cancer – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses chemosensitivity and chemoresistance assays in cancer. Applicable Procedure Codes: 0083U, 0564T, 81535, 81536, 86849, 89240.

Chromosome Microarray Testing (Non-Oncology Conditions) (for New Jersey Only) – Community Plan Medical Policy

Last Published 10.01.2020

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.

Chromosome Microarray Testing (Non-Oncology Conditions) (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2020

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.

Chromosome Microarray Testing (Non-Oncology Conditions) – Community Plan Medical Policy

Last Published 10.01.2020

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.

Cimzia® (Certolizumab Pegol) – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – 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.

Clinical Trials (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.

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Clinical Trials (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.

Clinical Trials (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.

Clinical Trials – Community Plan Coverage Determination Guideline

Last Published 05.01.2020

Effective Date: 05.01.2020 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.

Cochlear Implants (for Florida Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.

Cochlear Implants (for Nebraska Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 04.01.2019 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.

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Cochlear Implants (for New Jersey Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 04.01.2019 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.

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Cochlear Implants (for Tennessee Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.

Cochlear Implants – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Cognitive Rehabilitation (for Louisiana Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.

Cognitive Rehabilitation (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.

Cognitive Rehabilitation (for Tennessee Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.

Cognitive Rehabilitation – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2020 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.

Collagen Crosslinks and Biochemical Markers of Bone Turnover (for Louisiana Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.

Collagen Crosslinks and Biochemical Markers of Bone Turnover (for Nebraska Only) - Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 02.01.2019 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.

Collagen Crosslinks and Biochemical Markers of Bone Turnover (for New Jersey Only) - Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 02.01.2019 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.

Collagen Crosslinks and Biochemical Markers of Bone Turnover (for Tennessee Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.

Collagen Crosslinks and Biochemical Markers of Bone Turnover – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.

Complement Inhibitors (Soliris® & Ultomiris®) – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses the use of Soliris® (eculizumab) and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: J1300, J1303.

atypical hemolytic uremic syndrome (aHUS), paroxysmal nocturnal hemoglobinuria (PNH), generalized myasthenia gravis, and neuromyelitis optica spectrum disorder (NMOSD)

Complement Inhibitors (Soliris® & Ultomiris™) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 02.12.2020

Effective Date: 10.01.2019 – This policy addresses the use of Soliris® (eculizumab) for the treatment of atypical hemolytic uremic syndrome (aHUS), paroxysmal nocturnal hemoglobinuria (PNH), generalized myasthenia gravis, and neuromyelitis optica spectrum disorder (NMOSD), and the use of Ultomiris™ (ravulizumab-cwvz) for the treatment of paroxysmal nocturnal hemoglobinuria (PNH). Applicable Procedure Codes: J1300, J1303.

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Computed Tomographic Colonography (for Louisiana Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.

Computed Tomographic Colonography (for Nebraska Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2020 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.

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Computed Tomographic Colonography (for New Jersey Only) – Community Plan Medical Policy

Last Published 02.12.2020

Effective Date: 12.01.2018 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.

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Computed Tomographic Colonography (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2020

Effective Date: 01.01.2020 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.

Computed Tomographic Colonography – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

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.

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2021

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.

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

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.

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures – Community Plan Medical Policy

Last Published 01.01.2021

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.

Computerized Dynamic Posturography (for Louisiana Only) – Community Plan Medical Policy

Last Published 03.12.2020

Effective Date: 04.01.2019 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Code: 92548.

Effective Date: 04.01.2019 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548.,

Computerized Dynamic Posturography (for Nebraska Only) – Community Plan Medical Policy

Last Published 05.01.2020

Effective Date: 01.01.2020 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.

Computerized Dynamic Posturography (for Tennessee Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.

Computerized Dynamic Posturography – Community Plan Medical Policy

Last Published 05.01.2020

Effective Date: 05.01.2020 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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.

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for New Jersey Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

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Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 07.01.2020 – 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.

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

Core Decompression for Avascular Necrosis (for Louisiana Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.

Core Decompression for Avascular Necrosis (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 09.01.2019 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.

Core Decompression for Avascular Necrosis (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2019

Effective Date: 10.01.2019 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.

Core Decompression for Avascular Necrosis – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.

Corneal Hysteresis and Intraocular Pressure Measurement (for Louisiana Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 06.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – 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.

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Corneal Hysteresis and Intraocular Pressure Measurement (for Nebraska Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 06.01.2019 – 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.

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Corneal Hysteresis and Intraocular Pressure Measurement (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – 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.

Corneal Hysteresis and Intraocular Pressure Measurement – Community Plan Medical Policy

Last Published 07.01.2020

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.

Cosmetic and Reconstructive Procedures (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 03.11.2020

Effective Date: 08.01.2019 – This policy addresses cosmetic and reconstructive procedures.

11920, 11922, 11960, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15570, 15730, 15731, 15733, 15734, 15736, 15738, 15740, 15756, 15769, 15771, 15772, 15773, 15774, 17999, 19316, 19324, 19325, 21137, 21138, 21139, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21208, 21209, 21230, 21235, 21248, 21249, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21295, 21296, 21299, 28344, 30540, 30545, 30560, 30620, 67912, 11950, 11951, 11952, 11954, 15775, 15776, 15780, 15781, 15782, 15783, 15786, 15787,15788, 15789, 15792 , 15793, 15819, 15824, 15825, 15826, 15828, 15829, 17380, 21270, 69090, 69300, 36468, L8600, L8607, Q2026, Q2028,

Cosmetic and Reconstructive Procedures (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 06.01.2020

Effective Date: 01.01.2020 – This policy addresses cosmetic and reconstructive procedures.

11920, 11922, 11960, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15570, 15730, 15731, 15733, 15734, 15736, 15738, 15740, 15756, 15769, 15771, 15772, 15773, 15774, 17999, 19316, 19324, 19325, 21137, 21138, 21139, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21208, 21209, 21230, 21235, 21248, 21249, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21295, 21296, 21299, 28344, 30540, 30545, 30560, 30620, 67912, 11950, 11951, 11952, 11954, 15775, 15776, 15780, 15781, 15782, 15783, 15786, 15787,15788, 15789, 15792 , 15793, 15819, 15824, 15825, 15826, 15828, 15829, 17380, 21270, 69090, 69300, 36468, 36470, 36471, L8600, L8607, Q2026, Q2028,

Cosmetic and Reconstructive Procedures (for New Jersey Only) – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 07.01.2020 – This policy addresses cosmetic and reconstructive procedures.

Cosmetic and Reconstructive Procedures (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses cosmetic and reconstructive procedures.

Cosmetic and Reconstructive Procedures – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses cosmetic and reconstructive procedures.

Crysvita® (Burosumab-Twza) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses the use of Crysvita® (burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH). Applicable Procedure Code: J0584.

Crysvita® (Burosumab-Twza) (for Pennsylvania Only) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

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Crysvita® (Burosumab-Twza) – Community Plan Medical Benefit Drug Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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.

Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis (for Louisiana Only) – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.

Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.

Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Deep Brain and Cortical Stimulation (for Louisiana Only) – Community Plan Medical Policy

Last Published 03.11.2020

Effective Date: 01.01.2019 – 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.

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Deep Brain and Cortical Stimulation (for Tennessee Only) – Community Plan Medical Policy

Last Published 02.01.2020

Effective Date: 02.01.2020 – 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.

Deep Brain and Cortical Stimulation – Community Plan Medical Policy

Last Published 03.11.2020

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.

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Denied Drug Codes – Pharmacy Benefit Drugs (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – 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.

Denied Drug Codes – Pharmacy Benefit Drugs – Community Plan Medical Benefit Drug Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – 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.

Denosumab (Prolia® & Xgeva®) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses the use of denosumab (Prolia® & Xgeva®). Applicable Procedure Code: J0897.

Denosumab (Prolia® & Xgeva®) – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses the use of denosumab (Prolia® & Xgeva®). Applicable Procedure Code: J0897.

Discogenic Pain Treatment (for Louisiana Only) – Community Plan Medical Policy

Last Published 12.01.2020

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.

Discogenic Pain Treatment (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 10.01.2019 – 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.

Discogenic Pain Treatment (for Tennessee Only) – Community Plan Medical Policy

Last Published 11.01.2019

Effective Date: 11.01.2019 – 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.

Discogenic Pain Treatment – Community Plan Medical Policy

Last Published 12.01.2020

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.

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements (for Florida Only)

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

Effective Date: 10.01.2020 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 08.01.2020

Effective Date: 02.01.2020 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.

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Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements (for New Jersey Only) – Community Plan Coverage Determination Guideline

Last Published 02.01.2020

Effective Date: 10.01.2019 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.

Elbow Replacement Surgery (Arthroplasty) (for Louisiana Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 04.01.2020 (state-specific policy version created 07.01.2020; no change to policy guidelines) – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.

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Elbow Replacement Surgery (Arthroplasty) (for Nebraska Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 08.01.2020 – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.

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Elbow Replacement Surgery (Arthroplasty) (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 05.01.2020 – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.

Elbow Replacement Surgery (Arthroplasty) – Community Plan Medical Policy

Last Published 12.11.2020

Effective Date: 04.01.2020 – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.

Electric Tumor Treatment Field Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2020 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.

Electric Tumor Treatment Field Therapy (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

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.

Electric Tumor Treatment Field Therapy (for New Jersey Only) – Community Plan Medical Policy

Last Published 12.01.2020

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.

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Electric Tumor Treatment Field Therapy (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.

Electric Tumor Treatment Field Therapy – Community Plan Medical Policy

Last Published 12.01.2020

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.

Electrical and Ultrasound Bone Growth Stimulators (for Nebraska Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 08.01.2020 – This policy addresses electrical, electromagnetic, and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20975, 20979, E0747, E0748, E0749, E0760.

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Electrical and Ultrasound Bone Growth Stimulators (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 04.01.2020 – This policy addresses electrical, electromagnetic, and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20975, 20979, E0747, E0748, E0749, E0760.

Electrical and Ultrasound Bone Growth Stimulators (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 05.01.2020 – This policy addresses electrical, electromagnetic, and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20975, 20979, E0747, E0748, E0749, E0760.

Electrical and Ultrasound Bone Growth Stimulators – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.

Electrical Bioimpedance for Cardiac Output Measurement (for Louisiana Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.

Electrical Bioimpedance for Cardiac Output Measurement (for Nebraska Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 09.01.2019 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.

Electrical Bioimpedance for Cardiac Output Measurement (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.

Electrical Bioimpedance for Cardiac Output Measurement – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.

Electrical Stimulation and Electromagnetic Therapy for Wounds (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2020 – This policy addresses electrical stimulation and electromagnetic therapy for ulcers or wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.

Electrical Stimulation and Electromagnetic Therapy for Wounds (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

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.

Electrical Stimulation and Electromagnetic Therapy for Wounds (for Tennessee Only) – Community Plan Medical Policy

Last Published 05.01.2020

Effective Date: 05.01.2020 – This policy addresses electrical stimulation and electromagnetic therapy for treating ulcers or wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.

Electrical Stimulation and Electromagnetic Therapy for Wounds – Community Plan Medical Policy

Last Published 03.01.2020

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.

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (for Louisiana Only) – Community Plan Medical Policy

Last Published 01.01.2021

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.

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (for Nebraska Only) – Community Plan Medical Policy

Last Published 01.01.2021

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.

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Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (for New Jersey Only) – Community Plan Medical Policy

Last Published 02.12.2020

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.

functional electrical stimulation (FES), neuromuscular electrical stimulation (NMES), dorsal root ganglion (DRG) stimulation, interferential therapy (IFT), microcurrent electrical nerve stimulation (MENS), pulsed electrical stimulation (PES), peripheral subcutaneous field stimulation (PSFS) or peripheral nerve field stimulation (PNFS), percutaneous electrical nerve stimulation (PENS), percutaneous neuromodulation therapy (PNT), scrambler therapy (ST), percutaneous electrical nerve field stimulation (PENFS),

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.06.2020

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.

functional electrical stimulation (FES), neuromuscular electrical stimulation (NMES), dorsal root ganglion (DRG) stimulation, interferential therapy (IFT), microcurrent electrical nerve stimulation (MENS), pulsed electrical stimulation (PES), peripheral subcutaneous field stimulation (PSFS) or peripheral nerve field stimulation (PNFS), percutaneous electrical nerve stimulation (PENS), percutaneous neuromodulation therapy (PNT), scrambler therapy (ST), percutaneous electrical nerve field stimulation (PENFS)

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation – Community Plan Medical Policy

Last Published 01.01.2021

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.

Electroencephalographic (EEG) Monitoring and Video Recording (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.

Electroencephalographic (EEG) Monitoring and Video Recording (for New Jersey Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 05.01.2020 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.

Electroencephalographic (EEG) Monitoring and Video Recording (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 08.01.2020 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.

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Electroencephalographic (EEG) Monitoring and Video Recording – Community Plan Medical Policy

Last Published 12.11.2020

Effective Date: 04.01.2020 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.

Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for Louisiana Only) – Community Plan Medical Policy

Last Published 05.01.2020

Effective Date: 04.01.2019 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.

Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for Nebraska Only) – Community Plan Medical Policy

Last Published 05.01.2020

Effective Date: 04.01.2019 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.

Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for Tennessee Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.

Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome – Community Plan Medical Policy

Last Published 05.01.2020

Effective Date: 05.01.2020 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.

Emergency Health Care Services and Urgent Care Center Services (for Maryland Only) – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses outpatient emergency health care services, physician-ordered emergency department visits, and urgent care center services.

99217, 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, 99236, 99281, 99282, 99283, 99284, 99285, 99288, G0378, G0379, G0380, G0381, G0382, G0383, G0384, G0390, G2213, S9083, S9088

Entyvio® (Vedolizumab) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 05.01.2020

Effective Date: 01.01.2020 – 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.

Entyvio® (Vedolizumab) – Community Plan Medical Benefit Drug Policy

Last Published 09.01.2020

Effective Date: 05.01.2020 – 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.

Enzyme Replacement Therapy (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 08.06.2020

Effective Date: 10.01.2019 – 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.

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Enzyme Replacement Therapy – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

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.

Epidural Steroid and Facet Injections for Spinal Pain (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

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.

Epidural Steroid and Facet Injections for Spinal Pain (for New Jersey Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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.

Epidural Steroid and Facet Injections for Spinal Pain (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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.

Epidural Steroid and Facet Injections for Spinal Pain – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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.

Epiduroscopy, Epidural Lysis of Adhesions and Discography (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2020 – 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.

Epiduroscopy, Epidural Lysis of Adhesions and Discography (for Tennessee Only) – Community Plan Medical Policy

Last Published 02.12.2020

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.

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Epiduroscopy, Epidural Lysis of Adhesions and Discography – Community Plan Medical Policy

Last Published 04.01.2020

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.

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography (for New Jersey Only) – Community Plan Medical Policy

Last Published 08.21.2020

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.

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Erythropoiesis-Stimulating Agents (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 02.12.2020

Effective Date: 03.01.2019 – 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.

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Erythropoiesis-Stimulating Agents – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

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.

Evenity® (Romosozumab-Aqqg) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 07.01.2020

Effective Date: 10.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – 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.

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Evenity® (Romosozumab-Aqqg) – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

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.

Exondys 51® (Eteplirsen) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.

Exondys 51® (Eteplirsen) (for Pennsylvania Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2020

Effective Date: 04.01.2020 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.

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Exondys 51® (Eteplirsen) – Community Plan Medical Benefit Drug Policy

Last Published 09.01.2020

Effective Date: 04.01.2020 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.

Extracorporeal Shock Wave Therapy (ESWT) (for Louisiana Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 06.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – This policy addresses extracorporeal shock wave therapy (ESWT). Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.

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Extracorporeal Shock Wave Therapy (ESWT) (for Nebraska Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 06.01.2019 – This policy addresses extracorporeal shock wave therapy (ESWT). Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.

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Extracorporeal Shock Wave Therapy (ESWT) (for New Jersey Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 06.01.2019 – This policy addresses extracorporeal shock wave therapy (ESWT). Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.

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Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds (for Florida Only) – Community Plan Medical Policy

Last Published 09.01.2020

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.

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Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.

Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds – Community Plan Medical Policy

Last Published 10.01.2020

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.

Facet Injections for Spinal Pain (for Louisiana Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses facet injections for spinal pain. Applicable Procedure Codes: 64490, 64491, 64492, 64493, 64494, 64495.

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Fecal Calprotectin Testing (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2020 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.

Fecal Calprotectin Testing (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.

Fecal Calprotectin Testing (for New Jersey Only) – Community Plan Medical Policy

Last Published 05.13.2020

Effective Date: 06.01.2019 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.

Fecal Calprotectin Testing (for Tennessee Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.

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Fecal Calprotectin Testing – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.

Femoroacetabular Impingement Syndrome (for Louisiana Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses surgical treatment for femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27299, 29914, 29915, 29916, 29999.

Femoroacetabular Impingement Syndrome (for Nebraska Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 12.01.2019 – This policy addresses surgical treatment for femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27299, 29914, 29915, 29916, 29999.

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Femoroacetabular Impingement Syndrome (for Tennessee Only) – Community Plan Medical Policy

Last Published 02.12.2020

Effective Date: 01.01.2020 – This policy addresses surgical treatment for femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27299, 29914, 29915, 29916, 29999.

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Femoroacetabular Impingement Syndrome – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses surgical treatment for femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27299, 29914, 29915, 29916, 29999.

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood (for New Jersey Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 04.01.2020 – This policy addresses DNA-based noninvasive prenatal tests of fetal aneuploidy. Applicable Procedure Codes: 0060U, 0168U, 81420, 81422, 81479, 81507.

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Functional Endoscopic Sinus Surgery (FESS) (for Florida Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.

Functional Endoscopic Sinus Surgery (FESS) (for Louisiana Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2020 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.

Functional Endoscopic Sinus Surgery (FESS) (for Nebraska Only) – Community Plan Medical Policy

Last Published 09.01.2020

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.

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Functional Endoscopic Sinus Surgery (FESS) (for New Jersey Only) – Community Plan Medical Policy

Last Published 06.16.2020

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.

Functional Endoscopic Sinus Surgery (FESS) (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.

Functional Endoscopic Sinus Surgery (FESS) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.

Gamifant® (Emapalumab-Lzsg) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 07.01.2020

Effective Date: 10.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – This policy addresses the use of Gamifant® (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.

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Gamifant® (Emapalumab-Lzsg) – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses the use of Gamifant® (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.

Gamifant™ (Emapalumab-Lzsg) (for Pennsylvania Only) – Community Plan Medical Benefit Drug Policy

Last Published 10.12.2020

Effective Date: 10.01.2019 – This policy addresses the use of Gamifant™ (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.

Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Florida Only) – Community Plan Medical Policy

Last Published 07.01.2020

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.

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Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Louisiana Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 10.01.2020 – 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.

Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Nebraska Only) – Community Plan Medical Policy

Last Published 07.01.2020

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.

Gastrointestinal Motility Disorders, Diagnosis and Treatment (for New Jersey Only) – Community Plan Medical Policy

Last Published 07.01.2020

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.

Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Tennessee Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 08.01.2020 – 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.

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Gastrointestinal Motility Disorders, Diagnosis and Treatment – Community Plan Medical Policy

Last Published 07.01.2020

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.

Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea (for Tennessee Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 0097U, 87505, 87506, 87507.

Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 0097U, 87505, 87506, 87507.

Gender Dysphoria Treatment (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses gender dysphoria treatment, including gender reassignment surgery and certain ancillary procedures.

Gender Dysphoria Treatment – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.

Genetic Testing for Cardiac Disease (for Louisiana Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 10.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 81410, 81411, 81413, 81414, 81439, 81443, 81493.

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Genetic Testing for Cardiac Disease (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 81410, 81411, 81413, 81414, 81439, 81443, 81493.

Genetic Testing for Cardiac Disease (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.

Genetic Testing for Cardiac Disease – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.

Genetic Testing for Hereditary Cancer (for Louisiana Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.

Genetic Testing for Hereditary Cancer (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.

Genetic Testing for Hereditary Cancer (for Tennessee Only) – Community Plan Medical Policy

Last Published 02.01.2020

Effective Date: 02.01.2020 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.

0101U, 0102U, 0103U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0138U, 0162U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81432, 81433, 81435, 81436, 81437, 81438

Genetic Testing for Hereditary Cancer – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.

Genetic Testing for Neuromuscular Disorders (for Florida Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 12.01.2020 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 81440, 81460, 81465, 81479.

Genetic Testing for Neuromuscular Disorders (for New Jersey Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2019 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 81440, 81443, 81460, 81465, 81479.

Genetic Testing for Neuromuscular Disorders (for Tennessee Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 81440, 81460, 81465, 81479.

Genetic Testing for Neuromuscular Disorders – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 81440, 81460, 81465, 81479.

Genitourinary Pathogen Nucleic Acid Detection Panel Testing (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2021

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.

Genitourinary Pathogen Nucleic Acid Detection Panel Testing (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

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.

Genitourinary Pathogen Nucleic Acid Detection Panel Testing – Community Plan Medical Policy

Last Published 01.01.2021

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.

Givlaari® (Givosiran) (for Pennsylvania Only) – Community Plan Medical Benefit Drug Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.

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Givlaari® (Givosiran) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.

Glaucoma Surgical Treatments (for Louisiana Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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.

Glaucoma Surgical Treatments (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

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.

Glaucoma Surgical Treatments (for New Jersey Only) - Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 09.01.2019 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and viscocanalostomy. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 66170, 66174, 66175, 66179, 66180, 66183, 66184, L8612.

Glaucoma Surgical Treatments (for Tennessee Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – 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.

Glaucoma Surgical Treatments – Community Plan Medical Policy

Last Published 06.01.2020

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.

Gonadotropin Releasing Hormone Analogs (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products, including Firmagon (degarelix), Lupaneta Pack (leuprolide acetate injection and norethindrone acetate tablets), Lupron Depot (leuprolide acetate), Lupron Depot-Ped (leuprolide acetate), Supprelin LA (histrelin acetate), Trelstar (triptorelin pamoate), Triptodur (triptorelin), Vantas (histrelin acetate), and Zoladex (goserelin acetate). Applicable Procedure Codes: J1950, J3315, J3316, J3490, J9155, J9202, J9217, J9225, J9226.

Gonadotropin Releasing Hormone Analogs – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products. Applicable Procedure Codes: J1950, J3315, J3316, J9155, J9202, J9217, J9225, J9226.

Gynecomastia Treatment (for Florida Only) – Community Plan Coverage Determination Guideline

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.

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Gynecomastia Treatment (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 04.01.2020

Effective Date: 04.01.2020 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.

Gynecomastia Treatment (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 04.01.2020

Effective Date: 08.01.2019 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.

Gynecomastia Treatment (for New Jersey Only) – Community Plan Coverage Determination Guideline

Last Published 07.01.2020

Effective Date: 04.01.2020 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.

Gynecomastia Treatment (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.

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Gynecomastia Treatment – Community Plan Coverage Determination Guideline

Last Published 08.01.2020

Effective Date: 07.01.2020 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.

Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable (for Louisiana Only) – Community Plan Medical Policy

Last Published 03.11.2020

Effective Date: 02.01.2019 – 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.

92590, 92591, 92592, 92593, 92594, 92595, 69799, 69710, 69711, 69714, 69715, 69717, 69718, S0618, V5010, V5011, V5014, V5020, V5264, V5265, V5275, S2230, V5095, L8690, L8691, L8692, L8693, L8694, V5030, V5040, V5050, V5060, V5070, V5080, V5100, V5120, V5130, V5140, V5150, V5171, V5172, V5181, V5190, V5211, V5212, V5213, V5214, V5215, V5221, V5230, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5262, V5263, V5267, V5298,

Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2021

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.

Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable (for Tennessee Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – 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.

Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable – Community Plan Medical Policy

Last Published 01.01.2021

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.

Hepatitis Screening (for Louisiana Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 07.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – This policy addresses hepatitis screening. Applicable Procedure Codes: 81596, 86704, 86705, 86706, 86707, 86708, 86709, 86803, 86804, 87340, 87341, 87350, 87902, 87912, G0472, G0499.

Hepatitis Screening (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

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.

Hepatitis Screening (for New Jersey Only) – Community Plan Medical Policy

Last Published 10.14.2020

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.

Hepatitis Screening (for Tennessee Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses hepatitis screening. Applicable Procedure Codes: 86704, 86705, 86706, 86707, 86708, 86709, 86803, 86804, 87340, 87341, 87350, 87902, 87912, G0472, G0499.

Hepatitis Screening – Community Plan Medical Policy

Last Published 10.14.2020

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.

Hereditary Angioedema (HAE), Treatment and Prophylaxis (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 07.01.2020

Effective Date: 01.01.2020 (state-specific policy version created 07.01.2020; no change to policy guidelines) – 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), including the following drug products: Berinert® (for intravenous injection), Cinryze® (for intravenous injection), Ruconest® (for intravenous injection), and Kalbitor® (ecallantide, for subcutaneous injection). Applicable Procedure Codes: J0596, J0597, J0598, J1290.

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Hereditary Angioedema (HAE), Treatment and Prophylaxis – Community Plan Medical Benefit Drug Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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.

High Frequency Chest Wall Compression Devices (for Tennessee Only) – Community Plan Medical Policy

Last Published 02.12.2020

Effective Date: 12.01.2019 – This policy addresses high-frequency chest wall compression (HFCWC). Applicable Procedure Codes: A7025, A7026, E0483.

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High Frequency Chest Wall Compression Devices – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 11.01.2019 – This policy addresses high-frequency chest wall compression (HFCWC). Applicable Procedure Codes: A7025, A7026, E0483.

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Hip Resurfacing and Replacement Surgery (Arthroplasty) (for Florida Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.

Hip Resurfacing and Replacement Surgery (Arthroplasty) (for Louisiana Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 05.01.2020 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.

Hip Resurfacing and Replacement Surgery (Arthroplasty) (for Nebraska Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2019 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.

Hip Resurfacing and Replacement Surgery (Arthroplasty) (for New Jersey Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 05.01.2020 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.

Hip Resurfacing and Replacement Surgery (Arthroplasty) (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.

Hip Resurfacing and Replacement Surgery (Arthroplasty) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.

Home Health Care (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 04.01.2020

Effective Date: 10.01.2019 – This policy addresses home health care services.

Home Health Care (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses home health care services.

Home Health Care (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses home health care services.

Home Health Care – Community Plan Coverage Determination Guideline

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses home health care services.

Home Hemodialysis (for Louisiana Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.

Home Hemodialysis (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

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.

Home Hemodialysis (for Tennessee Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.

Home Hemodialysis – Community Plan Medical Policy

Last Published 04.01.2020

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.

Home Traction Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 05.01.2019 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.

Home Traction Therapy (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.

Home Traction Therapy (for Tennessee Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.

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Home Traction Therapy – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.

Hospice Care (for Florida Only) – Community Plan Coverage Determination Guideline

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses hospice and concurrent care services. Applicable Procedure Codes: T2042, T2043, T2044, T2045.

Hospice Care (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 03.12.2020

Effective Date: 07.01.2019 – This policy addresses hospice and concurrent care services. Applicable Procedure Codes: T2042, T2043, T2044, T2045.

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Hospice Care (for Mississippi Only) – Community Plan Coverage Determination Guideline

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses hospice and concurrent care services. Applicable Procedure Codes: T2042, T2043, T2044, T2045.

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Hospice Care (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses hospice and concurrent care services. Applicable Procedure Codes: T2042, T2043, T2044, T2045.

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Ilaris® (Canakinumab) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

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.

Ilumya™ (Tildrakizumab-Asmn) – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

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.

Immune Globulin (IVIG and SCIG) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, J1459, J1555, J1556, J1557, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599.

Immune Globulin (IVIG and SCIG) – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, C9072, J1459, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599.

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors (for Louisiana Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of malignant tumors. Applicable Procedure Codes: 37243, 79445, S2095.

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

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.

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors (for Tennessee Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of malignant tumors. Applicable Procedure Codes: 37243, 79445, S2095.

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors – Community Plan Medical Policy

Last Published 04.01.2020

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.

Implanted Electrical Stimulator for Spinal Cord (for Louisiana Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 04.01.2020 (state-specific policy version created 07.01.2020; no change to policy guidelines) – 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.

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Implanted Electrical Stimulator for Spinal Cord (for Nebraska Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 08.01.2020 – 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.

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Implanted Electrical Stimulator for Spinal Cord (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 05.01.2020 – 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.

Implanted Electrical Stimulator for Spinal Cord – Community Plan Medical Policy

Last Published 12.11.2020

Effective Date: 04.01.2020 – 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.

Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

Inhaled Nitric Oxide for Infants – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

Intensity-Modulated Radiation Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – 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.

Intensity-Modulated Radiation Therapy (for New Jersey Only) – Community Plan Medical Policy

Last Published 03.01.2020

Effective Date: 01.01.2019 – 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.

Intensity-Modulated Radiation Therapy (for Tennessee Only) – Community Plan Medical Policy

Last Published 03.01.2020

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.

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Intensity-Modulated Radiation Therapy – Community Plan Medical Policy

Last Published 03.01.2020

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.

Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) (for Florida Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.

Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) (for Louisiana Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 06.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.

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Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 06.01.2019 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.

Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) (for New Jersey Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 06.01.2019 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.

Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) (for Tennessee Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.

Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.

Intrauterine Fetal Surgery (for Louisiana Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses intrauterine fetal surgery. Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.

Intrauterine Fetal Surgery (for Nebraska Only) – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Intrauterine Fetal Surgery (for New Jersey Only) – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Intrauterine Fetal Surgery (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – This policy addresses intrauterine fetal surgery. Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.

Intrauterine Fetal Surgery – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 01.01.2020 (state-specific policy version created 12.01.2020; no change to policy guidelines) – 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.

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

Intravenous Iron Replacement Therapy (Feraheme® & Injectafer®) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses the use of intravenous iron replacement therapy with Feraheme® (ferumoxytol) and Injectafer® (ferric carboxymaltose) for the treatment of iron deficiency anemia (IDA) with and without chronic kidney disease (CKD). Applicable Procedure Codes: J1439, Q0138.

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Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

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.

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Ketalar® (Ketamine) and Spravato® (Esketamine) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses the use of Ketalar® (ketamine) for anesthesia purposes and Spravato® (esketamine) for the treatment of treatment-resistant depression (TRD). Applicable Procedure Code: J3490.

Knee Replacement Surgery (Arthroplasty), Total and Partial (for Florida Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.

Knee Replacement Surgery (Arthroplasty), Total and Partial (for Louisiana Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.

Knee Replacement Surgery (Arthroplasty), Total and Partial (for Nebraska Only) – Community Plan Medical Policy

Last Published 04.01.2020

Effective Date: 04.01.2019 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.

Knee Replacement Surgery (Arthroplasty), Total and Partial (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.

Knee Replacement Surgery (Arthroplasty), Total and Partial (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.

Knee Replacement Surgery (Arthroplasty), Total and Partial – Community Plan Medical Policy

Last Published 12.11.2020

Effective Date: 10.01.2020 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.

Krystexxa® (Pegloticase) – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

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.

Laser Interstitial Thermal Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 09.01.2019 (state-specific policy version created 07.01.2020; no change to policy guidelines) – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 64999.

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Laser Interstitial Thermal Therapy (for Nebraska Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 09.01.2019 – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 64999.

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Laser Interstitial Thermal Therapy (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 64999.

Laser Interstitial Thermal Therapy – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 64999.

Lemtrada (Alemtuzumab) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 05.01.2020

Effective Date: 01.01.2020 – This policy addresses the use of Lemtrada (alemtuzumab) for treatment of relapsing forms of multiple sclerosis. Applicable Procedure Code: J0202.

Lemtrada (Alemtuzumab) – Community Plan Medical Benefit Drug Policy

Last Published 09.01.2020

Effective Date: 05.01.2020 – This policy addresses the use of Lemtrada (alemtuzumab) for treatment of relapsing forms of multiple sclerosis. Applicable Procedure Code: J0202.

Light and Laser Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 11.02.2020

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.

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Light and Laser Therapy (for Nebraska Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 08.01.2019 – 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.

Light and Laser Therapy (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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.

Light and Laser Therapy – Community Plan Medical Policy

Last Published 11.01.2020

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.

Lithotripsy for Salivary Stones (for Louisiana Only) – Community Plan Medical Policy

Last Published 11.01.2020

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.

Lithotripsy for Salivary Stones (for Nebraska Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 10.01.2019 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.

Lithotripsy for Salivary Stones (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.

Lithotripsy for Salivary Stones – Community Plan Medical Policy

Last Published 11.01.2020

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.

Lower Extremity Invasive Diagnostic and Endovascular Procedures (for Nebraska Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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.

Lower Extremity Invasive Diagnostic and Endovascular Procedures (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – 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.

Lower Extremity Invasive Diagnostic and Endovascular Procedures – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 12.01.2020 – 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.

Lower Extremity Vascular Angiography (for New Jersey Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 05.01.2020 – This policy addresses lower extremity vascular angiography for evaluating arterial disease of the lower extremity. Applicable Procedure Codes: 75710, 75716.

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Luxturna® (Voretigene Neparvovec-Rzyl) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 11.01.2019 (state-specific policy version created 12.01.2020; no change to policy guidelines) – 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.

Luxturna® (Voretigene Neparvovec-Rzyl) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

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.

Macular Degeneration Treatment Procedures (for Louisiana Only) – Community Plan Medical Policy

Last Published 06.01.2020

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.

Macular Degeneration Treatment Procedures (for Nebraska Only) – Community Plan Medical Policy

Last Published 06.01.2020

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.

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Macular Degeneration Treatment Procedures (for Tennessee Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 08.01.2020 – 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.

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Macular Degeneration Treatment Procedures – Community Plan Medical Policy

Last Published 06.01.2020

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.

Manipulation Under Anesthesia (for Louisiana Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.

Manipulation Under Anesthesia (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

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.

Manipulation Under Anesthesia (for New Jersey Only) - Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 02.01.2019 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 24300, 25259, 26340, 27198, 27275, 27570, 27860, D7830.

Manipulation Under Anesthesia (for Tennessee Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.

Manipulation Under Anesthesia – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.

Manipulative Therapy (for Florida Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98940, 98941, 98942, 98943, S8990.

Manipulative Therapy (for Louisiana Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 05.01.2019 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.

Manipulative Therapy (for Nebraska Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 05.01.2019 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.

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Manipulative Therapy (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.

Manipulative Therapy – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.

Maximum Dosage and Frequency (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.

Maximum Dosage and Frequency – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 10.01.2020 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.

Mechanical Stretching Devices (for Louisiana Only) – Community Plan Medical Policy

Last Published 01.01.2021

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.

Mechanical Stretching Devices (for Nebraska Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 11.01.2019 – 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.

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Mechanical Stretching Devices (for Tennessee Only) – Community Plan Medical Policy

Last Published 12.01.2019

Effective Date: 12.01.2019 – 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.

Mechanical Stretching Devices – Community Plan Medical Policy

Last Published 01.01.2021

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.

Meniscus Implant and Allograft (for Louisiana Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.

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Meniscus Implant and Allograft (for Nebraska Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 06.01.2019 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.

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Meniscus Implant and Allograft (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.

Meniscus Implant and Allograft – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.

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Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) (for Louisiana Only) – Community Plan Medical Policy

Last Published 03.11.2020

Effective Date: 01.01.2019 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD). Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43499, 43999.

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Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) (for Nebraska Only) – Community Plan Medical Policy

Last Published 11.01.2020

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.

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) (for New Jersey Only) – Community Plan Medical Policy

Last Published 11.01.2020

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.

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) and Achalasia (for Tennessee Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – 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.

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) and Achalasia – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 11.01.2020 – 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.

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions (for Louisiana Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions (for New Jersey Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 10.01.2020 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.

Motorized Spinal Traction (for Louisiana Only) – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 05.01.2019 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.

Motorized Spinal Traction (for Nebraska Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.

Motorized Spinal Traction (for Tennessee Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 08.01.2020 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.

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Motorized Spinal Traction – Community Plan Medical Policy

Last Published 06.01.2020

Effective Date: 06.01.2020 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.

Negative Pressure Wound Therapy (for New Jersey Only) – Community Plan Medical Policy

Last Published 03.01.2020

Effective Date: 07.01.2019 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.

Negative Pressure Wound Therapy (for Tennessee Only) – Community Plan Medical Policy

Last Published 03.01.2020

Effective Date: 03.01.2020 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.

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Negative Pressure Wound Therapy – Community Plan Medical Policy

Last Published 03.01.2020

Effective Date: 03.01.2020 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.

Nerve Graft to Restore Erectile Function During Radical Prostatectomy (for Louisiana Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses sural or other nerve grafts to restore erectile function during radical prostatectomy. Applicable Procedure Codes: 55899, 64999.

Nerve Graft to Restore Erectile Function During Radical Prostatectomy (for Tennessee Only) – Community Plan Medical Policy

Last Published 12.01.2019

Effective Date: 12.01.2019 – This policy addresses sural or other nerve grafts to restore erectile function during radical prostatectomy. Applicable Procedure Codes: 55899, 64999.

Nerve Graft to Restore Erectile Function During Radical Prostatectomy – Community Plan Medical Policy

Last Published 03.11.2020

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.

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Neurophysiologic Testing and Monitoring (for Louisiana Only) – Community Plan Medical Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses nerve conduction studies and other neurophysiological testing.

Neurophysiologic Testing and Monitoring (for Tennessee Only) – Community Plan Medical Policy

Last Published 10.01.2019

Effective Date: 10.01.2019 – This policy addresses nerve conduction studies and other neurophysiological testing.

0106T, 0107T, 0108T, 0109T, 0110T, 0464T, 0533T, 0534T, 0535T, 0536T, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95873, 95874, 95885, 95886, 95887, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95937, 95999, 96002, 96003, 96004, A9279, A9280, G0255, S3900

Neurophysiologic Testing and Monitoring – Community Plan Medical Policy

Last Published 03.11.2020

Effective Date: 09.01.2019 – This policy addresses nerve conduction studies and other neurophysiological testing.

0106T, 0107T, 0108T, 0109T, 0110T, 0464T, 0533T, 0534T, 0535T, 0536T, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95873, 95874, 95885, 95886, 95887, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95937, 95999, 96002, 96003, 96004, A9279, A9280, G0255, S3900

Neuropsychological Testing Under the Medical Benefit (for Louisiana Only) – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Neuropsychological Testing Under the Medical Benefit (for Nebraska Only) – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Neuropsychological Testing Under the Medical Benefit (for Tennessee Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – 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.

Neuropsychological Testing Under the Medical Benefit – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Obstructive Sleep Apnea Treatment (for Louisiana Only) – Community Plan Medical Policy

Last Published 09.24.2020

Effective Date: 04.01.2020 – 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.

Obstructive Sleep Apnea Treatment (for Nebraska Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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.

Obstructive Sleep Apnea Treatment (for New Jersey Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 04.01.2020 – 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.

Obstructive Sleep Apnea Treatment (for Tennessee Only) – Community Plan Medical Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – 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.

Obstructive Sleep Apnea Treatment – Community Plan Medical Policy

Last Published 12.11.2020

Effective Date: 10.01.2020 – 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.

Occipital Neuralgia and Headache Treatment (for Florida Only) – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Occipital Neuralgia and Headache Treatment (for Louisiana Only) – Community Plan Medical Policy

Last Published 03.11.2020

Effective Date: 04.01.2019 – 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.

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Occipital Neuralgia and Headache Treatment (for Nebraska Only) – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Occipital Neuralgia and Headache Treatment (for New Jersey Only) – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Occipital Neuralgia and Headache Treatment (for Tennessee Only) – Community Plan Medical Policy

Last Published 09.01.2020

Effective Date: 09.01.2020 – 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.

Occipital Neuralgia and Headache Treatment – Community Plan Medical Policy

Last Published 08.01.2020

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.

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Ocrevus® (Ocrelizumab) (for New Jersey, New York, and Ohio Only) – Community Plan Medical Benefit Drug Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses the use of Ocrevus® (ocrelizumab) for the treatment of multiple sclerosis. Applicable Procedure Code: J2350.

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Ocrevus® (Ocrelizumab) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses the use of Ocrevus® (ocrelizumab) for the treatment of multiple sclerosis. Applicable Procedure Code: J2350.

Off-Label/Unproven Specialty Drug Treatment (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 12.01.2020

Effective Date: 12.01.2020 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.

Off-Label/Unproven Specialty Drug Treatment – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.

Omnibus Codes (for Florida Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses multiple services/procedures.

Omnibus Codes (for Louisiana Only) – Community Plan Medical Policy

Last Published 07.01.2020

Effective Date: 07.01.2020 – This policy addresses multiple services/procedures.

Omnibus Codes (for Nebraska Only) – Community Plan Medical Policy

Last Published 08.01.2020

Effective Date: 02.01.2020 – This policy addresses multiple services/procedures.

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Omnibus Codes (for New Jersey Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses multiple services/procedures.

Omnibus Codes (for Pennsylvania Only) – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses multiple services/procedures.

Omnibus Codes (for Tennessee Only) – Community Plan Medical Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses multiple services/procedures.

Omnibus Codes – Community Plan Medical Policy

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses multiple services/procedures.

Oncology Medication Clinical Coverage (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 02.01.2020

Effective Date: 03.01.2019 – This policy addresses parameters for coverage of injectable oncology medications and select ancillary and supportive care medications for oncology conditions covered under the medical benefit. Applicable Procedure Codes: J0640, J0641, J1950, J2353, J2354, J9000-J9999.

Oncology Medication Clinical Coverage – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

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.

Onpattro® (Patisiran) (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses the use of Onpattro® (patisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedure Code: J0222.

Onpattro® (Patisiran) – Community Plan Medical Benefit Drug Policy

Last Published 09.01.2020

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.

Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – This policy addresses the use of vascular endothelial growth factor (VEGF) inhibitors. Applicable Procedure Codes: J0178, J0179, J2503, J2778, J9035, Q5107, Q5118.

Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors – Community Plan Medical Benefit Drug Policy

Last Published 01.01.2021

Effective Date: 01.01.2021 – This policy addresses the use of vascular endothelial growth factor (VEGF) inhibitors. Applicable Procedure Codes: J0178, J0179, J2503, J2778, J9035, Q5107, Q5118.

Oral and Enteral Nutrition (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 06.01.2020

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.

Oral and Enteral Nutrition (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 06.01.2020

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.

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Oral and Enteral Nutrition (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 10.01.2020 – 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.

Oral and Enteral Nutrition – Community Plan Coverage Determination Guideline

Last Published 06.01.2020

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.

Orencia® (Abatacept) Injection for Intravenous Infusion (for Louisiana Only) – Community Plan Medical Benefit Drug Policy

Last Published 04.01.2020

Effective Date: 01.01.2020 – This policy addresses the use of Orencia® (abatacept) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, and psoriatic arthritis. Applicable Procedure Code: J0129.

Orencia® (Abatacept) Injection for Intravenous Infusion – Community Plan Medical Benefit Drug Policy

Last Published 11.01.2020

Effective Date: 11.01.2020 – 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.

Orthognathic (Jaw) Surgery (for Louisiana Only) – Community Plan Coverage Determination Guideline

Last Published 09.24.2020

Effective Date: 07.01.2020 – This policy addresses orthognathic (jaw) surgery.

21076, 21079, 21080, 21081, 21082, 21083, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215, 21244, 21245, 21246, 21247, D5934, D5935, D5982, D5988, D7471, D7472, D7473, D7490, D7610, D7630, D7650, D7671, D7680, D7710, D7730, D7750, D7770, D7780, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7953, D7955, D7995, D7996, D7997

Orthognathic (Jaw) Surgery (for Nebraska Only) – Community Plan Coverage Determination Guideline

Last Published 09.24.2020

Effective Date: 08.01.2020 – This policy addresses orthognathic (jaw) surgery.

21076, 21079, 21080, 21081, 21082, 21083, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215, 21244, 21245, 21246, 21247, D5934, D5935, D5982, D5988, D7471, D7472, D7473, D7490, D7610, D7630, D7650, D7671, D7680, D7710, D7730, D7750, D7770, D7780, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7953, D7955, D7995, D7996, D7997

Orthognathic (Jaw) Surgery (for New Jersey Only) – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 04.01.2020 – This policy addresses orthognathic (jaw) surgery.

Orthognathic (Jaw) Surgery (for Tennessee Only) – Community Plan Coverage Determination Guideline

Last Published 10.01.2020

Effective Date: 10.01.2020 – This policy addresses orthognathic (jaw) surgery.

Orthognathic (Jaw) Surgery – Community Plan Coverage Determination Guidel