A monthly notice of recently approved and/or revised Clinical and Administrative Policies 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 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 Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
Last Published 03.01.2022
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
Last Published 04.01.2022
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical and Administrative Policies.
Last Published 05.11.2022
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
Last Published 05.01.2022
A listing of the Oxford Policy Update Bulletins for the past two rolling years.
Current Policies
A complete library of the UnitedHealthcare® Oxford Clinical and Administrative Policies is available here for your reference. The appearance of an item or procedure on the list indicates only that we have adopted a policy; it does not imply that we provide coverage for the item or procedure listed.
The services described in our policies are subject to the terms, conditions and limitations of the member's contract or certificate. We reserve the right, in our sole discretion, to modify policies as necessary without prior written notice unless otherwise required by our administrative procedures or applicable state law. The terms "our" and "we" include Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.
Certain policies may not be applicable to self-funded members and certain insured products. Refer to the member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member's plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.
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Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses conventional thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 27299, 64625, 64628, 64629, 64633, 64634, 64635, 64636, 64999.
Last Published 05.01.2022
Effective Date: 05.01.2022 – 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, 58674, J7296, J7297, J7298, J7301, J7306, S4981.
Last Published 05.01.2022
Effective Date: 01.01.2022 – This policy addresses therapeutic and elective abortions. Applicable Procedure Codes: 59100, 59120, 59121, 59130, 59136, 59140, 59150, 59151, 59812, 59820, 59821, 59830, 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866, 59870, S0199, S2260, S2265, S2266, S2267.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses accreditation requirements for radiologists, radiology centers, and multi-speciality provider groups interested in participating in the UnitedHealthcare Oxford network.
Last Published 05.09.2022
Effective Date: 12.01.2021 – This policy addresses the exception process for the experimental/investigational treatment (drug therapy) of an acquired rare disease.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses airway clearance devices, such as high-frequency chest wall oscillation systems, and intrapulmonary percussive ventilation (IPV) devices. Applicable Procedure Codes: A7025, A7026, E0481, E0483.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.
Last Published 04.01.2022
Effective Date: 01.01.2022 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses autologous chondrocyte transplantation (ACT), osteochondral autograft and allograft transplantation, microfracture repair of the knee, and focal articular cartilage repair. Applicable Procedure Codes: 27412, 27415, 27416, 28446, 29866, 29867, 29879, J7330, S2112.
Last Published 01.25.2022
Effective Date: 06.01.2020 – This policy addresses assignment of benefits for services rendered by non-network providers and balance billing.
Last Published 01.25.2022
Effective Date: 07.01.2021 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses home sleep apnea testing, attended full-channel nocturnal polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, and attended PAP titration. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses services for the treatment of autism spectrum disorder and developmental disabilities.
Last Published 01.25.2022
Effective Date: 10.01.2021 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 27599.
Last Published 01.25.2022
Effective Date: 08.01.2021 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298, 31299.
Last Published 05.02.2022
Effective Date: 05.01.2022 – This policy addresses bariatric surgical procedures. Applicable Procedure Codes: 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
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses hospital beds, mattresses, and accessories. Applicable Procedure Codes: E0193, E0194, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0271, E0272, E0273, E0274, E0277, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0305, E0310, E0315, E0316, E0328, E0329, E0910, E0911, E0912, E0940.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses behavioral health services for the treatment of mental health and substance use disorders.
Last Published 01.25.2022
Effective Date: 04.01.2021 – This policy addresses upper and lower eyelid blepharoplasty, upper eyelid blepharoptosis repair, brow ptosis, eyelid surgery with an anophthalmic socket, ectropion or punctal eversion, entropion, lid retraction surgery, canthoplasty/canthopexy, and repair of floppy eyelid syndrome (FES).
Last Published 01.01.2022
Effective Date: 01.01.2022 – 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, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 76376, 76377, 76391, 76498, 76499, 76641, 76642, 77046, 77047, 77048, 77049, 77065, 77066, 77067, S8080.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses breast reconstruction post-mastectomy and for treatment of Poland syndrome. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15771, 15772, 15777, 19301, 19302, 19303, 19305, 19306, 19307, 19316, 19318, 19325, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.
Last Published 01.25.2022
Effective Date: 08.01.2021 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0650T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272, 93285, 93291, 93298, E0616, G2066.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses cardiology procedures requiring precertification with initial review performed by eviCore healthcare.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0052U, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.
Last Published 01.25.2022
Effective Date: 09.01.2021 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 81412, 81443, 81479.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses catheter ablation for atrial fibrillation. Applicable Procedure Codes: 93653, 93655, 93656, 93657.
Last Published 01.25.2022
Effective Date: 10.01.2021 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 81420, 81422, 81479, 81507.
Last Published 01.25.2022
Effective Date: 05.01.2021 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.
Last Published 01.01.2022
Effective Date: 01.01.2022 – 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, 81349, 81479, S3870.
Last Published 01.25.2022
Effective Date: 01.01.2021 – This policy addresses recovery of claim overpayments.
Last Published 01.25.2022
Effective Date: 02.01.2021 – This policy addresses the review of clinical information for the purposes of determining eligibility of coverage, prior authorization of medical services, and claim payment.
Last Published 01.25.2022
Effective Date: 05.01.2021 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses the payment methodology utilized by Oxford for claims determinations when multiple procedures are performed in the same session by the same provider.
Last Published 01.25.2022
Effective Date: 10.01.2021 – 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 Procedures Codes: 0054T, 0055T, 20985.
Last Published 01.25.2022
Effective Date: 05.01.2021 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4211, A4226, A4238, A9274, A9276, A9277, A9278, E0784, E0787, E1399, E2102, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.
Last Published 05.01.2022
Effective Date: 09.01.2020 – This policy addresses contraceptive procedures/appliances/devices and injectable drugs provided in a physician’s office.
Last Published 01.25.2022
Effective Date: 03.01.2021 – This policy addresses the order in which insurance plans pay claims when an individual has coverage under more than one plan.
Last Published 01.25.2022
Effective Date: 12.01.2021 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Last Published 01.25.2022
Effective Date: 08.01.2021 – This policy addresses measurement of corneal hysteresis, measurement of ocular blood flow, and monitoring of intraocular pressure. Applicable Procedure Codes: 0198T, 0329T, 66999, 67299, 92145.
Last Published 05.02.2022
Effective Date: 05.01.2022 – This policy addresses cosmetic and reconstructive procedures.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses credentialing guidelines for radiologists and cardiologists interested in participating in the eviCore healthcare network.
Last Published 01.25.2022
Effective Date: 09.01.2021 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses deep brain stimulation and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Last Published 01.25.2022
Effective Date: 04.01.2021 – This policy addresses oral surgical and dental procedures and related anesthesia when determined to be medical in nature.
Last Published 01.25.2022
Effective Date: 06.01.2021 – This policy addresses supplies, medications, and equipment for the treatment of diabetes.
Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses dialysis services. Applicable Procedure Codes: 90935, 90937, 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90967, 90968, 90969, 90970, 90989, 90993, 90997, 90999, G0257, G0491, G0492.
Last Published 02.15.2021
Effective Date: 09.01.2020 – This policy addresses certain information disclosed to members regarding their claims for benefits covered under their certificates or appeals of adverse benefit determinations.
Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses annular closure devices (ACDs), percutaneous injection of allogeneic cellular/tissue-based products, percutaneous discectomy and decompression procedures, and thermal intradiscal procedures (TIPs) for treating discogenic pain. Applicable Procedure Codes: 0627T, 0628T, 0629T, 0630T, 22526, 22527, 22899, 62287, 62380, S2348.
Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.
Last Published 01.25.2022
Effective Date: 09.01.2021 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses electrical stimulation and electromagnetic therapy for wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.
Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Applicable Procedure Codes: 0278T, 63650, 63655, 63663, 63664, 63685, 64555, 64999, E0744, E0745, E0762, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Last Published 01.25.2022
Effective Date: 09.01.2021 – This policy addresses emergency room visits, including services provided outside of the United States.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses epidural steroid injections for spinal pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484.
Last Published 01.01.2022
Effective Date: 01.01.2022 – 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, 62291, 62292, 64999, 72285, 72295.
Last Published 05.01.2022
Effective Date: 12.01.2021 – This policy addresses experimental and/or investigational treatment or procedures for New Jersey (NJ) Plans.
Last Published 05.01.2022
Effective Date: 12.01.2021 – This policy addresses experimental and/or investigational treatment or procedures.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses extended benefits for totally disabled members, including when a member changes carriers while confined in an inpatient facility.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses facet joint injections/medial branch blocks for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495.
Last Published 01.25.2022
Effective Date: 06.01.2021 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses fertility preservation for medical reasons that cause irreversible infertility. Applicable Procedure Codes: 58970, 89250, 89251, 89253, 89254, 89258, 89259, 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89320, 89337, 89342, 89343, 89346, S0122, S0126, S0128, S0132, S4011, S4022, S4027, S4030, S4031, S4040, J0725, J3355.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses timeframes for submission of original claims, additional information, and appeals.
Last Published 02.02.2021
Effective Date: 10.01.2020 – This policy addresses follow-up care when rendered in an emergency room (ER) site of service/setting.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses specialized formula and foods, including enteral formulas, nutritional formulas, and pasteurized donor human milk. Applicable Procedure Codes: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9432, S9433, S9434, S9435, T2101.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Last Published 01.25.2022
Effective Date: 07.01.2021 – 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, 72195, 72196, 72197, 76496, 91117, 91120, 91122, 91132, 91133.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 87505, 87506, 87507.
Last Published 05.01.2022
Effective Date: 10.01.2021 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.
Last Published 01.25.2022
Effective Date: 07.01.2021 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.
Last Published 01.25.2022
Effective Date: 12.01.2021 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.
Last Published 01.25.2022
Effective Date: 10.01.2021 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 0216U, 0217U, 81440, 81460, 81465, 81479.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses genitourinary pathogen nucleic acid detection panel testing to evaluate symptomatic women for vaginitis. Applicable Procedure Codes: 0068U, 87480, 81513, 81514, 87481, 87482, 87510, 87511, 87512, 87660, 87661, 87797, 87798, 87799, 87800, 87801.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and gonioscopy-assisted transluminal trabeculotomy. Applicable Procedure Codes: 0253T, 0449T, 0450T, 0474T, 0671T, 65820, 66174, 66175, 66179, 66180, 66183, 66184, 66185, 66989, 66991, C1889, L8612.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.
Last Published 05.11.2022
Effective Date: 08.01.2021 – This policy addresses home health care services.
Last Published 01.25.2022
Effective Date: 05.01.2021 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Last Published 01.25.2022
Effective Date: 07.01.2021 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.
Last Published 05.11.2022
Effective Date: 08.01.2021 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of malignant tumors. Applicable Procedure Codes: 37243, 79445, S2095.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses implanted electrical spinal cord and dorsal root ganglion (DRG) stimulation. Applicable Procedure Codes: 63650, 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses implanted spinal drug delivery systems for the treatment of cancer-related pain, severe spasticity, and chronic non-malignant pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses in-network exceptions for breast reconstruction surgery after mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19316, 19325, 19330, 19340, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, 19396, 19499, 19318, L8600, S2066, S2067, S2068, S8950.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses laboratory testing/procedures that Oxford Network physicians may provide in their offices, including specimen handling and venipuncture.
Last Published 05.01.2022
Effective Date: 01.01.2022 – This policy addresses diagnostic and therapeutic procedures for infertility and cryopreservation.
Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses the use of inhaled nitric oxide (iNO) for treating term or near-term infants with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN). Applicable Procedure Code: 94799.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses the state mandated length of inpatient stay for mother and baby following delivery and subsequent home nursing visits.
Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses the use of intensity-modulated radiation therapy (IMRT). Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses intrauterine fetal surgery (IUFS) and fetoscopic endoluminal tracheal occlusion (FETO) . Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 61736, 61737, 64999.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 17106, 17107, 17108, 17380.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses liposuction for lipedema when used to treat functional impairment. Applicable Procedure Codes: 15877, 15878, 15879.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses lower extremity vascular angiography and endovascular revascularization procedures. Applicable Procedure Codes: 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235, 75710, 75716.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses the use of parenteral antibiotics for treating Lyme disease. Applicable Procedure Codes: J0456, J0558, J0561, J0696, J0698, J2510, J2540.
Last Published 01.25.2022
Effective Date: 07.01.2021 – This policy addresses implantable miniature telescope (IMT), conjunctival incision with posterior extrascleral placement of a pharmacologic agent, laser photocoagulation, and radiation therapy. Applicable Procedure Codes: 0308T, 67036, 67299, 92499.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses advanced radiologic imaging procedures performed in a hospital outpatient department.
Last Published 01.25.2022
Effective Date: 04.01.2021 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.
Last Published 01.25.2022
Effective Date: 07.01.2021 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses manual wheelchairs.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841.
Last Published 01.25.2022
Effective Date: 12.01.2021 – This policy addresses the process and timeframes of an administrative grievance/appeal.
Last Published 01.25.2022
Effective Date: 09.01.2021 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.
Last Published 05.01.2022
Effective Date: 05.01.2022 – 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, 43497, 43499, 43999.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.
Last Published 01.25.2022
Effective Date: 07.01.2021 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.
Last Published 01.25.2022
Effective Date: 12.01.2021 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy . Applicable Procedure Codes: 55899, 64999.
Last Published 01.25.2022
Effective Date: 12.01.2021 – This policy addresses nerve conduction studies and other neurophysiological testing.
Last Published 01.25.2022
Effective Date: 09.01.2021 – This policy addresses neuropsychological testing and computerized cognitive testing under the medical benefit. Applicable Procedure Codes: 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses enrollment and coverage of newborns.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses observation services in a hospital setting.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses obstetrical ultrasounds. Applicable Procedure Codes: 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76818, 76819, 76820, 76821, 76825, 76826, 76827, 76828.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, 21142, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, 64582, 64583, 64584, E0485, E0486, E1399, K1001, K1027, K1028, K1029, L8679, L8680, L8686, S2080, S2900.
Last Published 05.01.2022
Effective Date: 01.01.2022 – This policy addresses occipital neuralgia and headache treatments, including occipital nerve blocks and occipital nerve ablation. Applicable Procedure Codes: 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64633, 64634, 64722, 64744, 64771, 64999, K1023, L8679, L8680, L8685.
Last Published 01.25.2022
Effective Date: 08.01.2021 – This policy addresses certain elective procedures that are typically performed in an office setting but may be performed in an ambulatory surgical center in certain circumstances. Applicable Procedure Codes: 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11442, 19000, 20552, 20553, 27096, 31579, 57460, 62270, 62321, 64479, 64490, 64493, 64633, 64635.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses multiple services/procedures.
Last Published 05.01.2022
Effective Date: 04.01.2022 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Codes: J0640, J0641, J0642, J1950, J3315, J9035, J9155, J9198, J9199, J9201, J9202, J9217, J9218, J9219, J9310, J9312, J9316, J9355, J9356, Q5107, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses orthognathic (jaw) surgery.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses services subject to utilization review with OrthoNet’s orthopedic division.
Last Published 01.25.2022
Effective Date: 10.01.2021 – This policy addresses neonatal hearing screening, auditory screening, and diagnostic testing using otoacoustic emissions (OAEs). Applicable Procedure Codes: 92558, 92587, 92588.
Last Published 01.25.2022
Effective Date: 10.01.2021 – This policy addresses outpatient physical and occupational therapy services managed by OptumHealth Care Solutions.
Last Published 02.01.2022
Effective Date: 02.01.2022 – This policy addresses the medical necessity of certain planned surgical procedures when performed in a hospital outpatient department.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses self-referral for outpatient imaging services.
Last Published 01.25.2022
Effective Date: 10.01.2021 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.
Last Published 06.01.2021
Effective Date: 05.01.2020 – This policy addresses participating gastroenterologists located in New York performing non-emergent procedures using nonparticipating anesthesiologists in office (IO) or in an ambulatory surgery center (ASC).
Last Published 08.24.2021
Effective Date: 05.01.2020 – This policy addresses participating providers treating a member on a Connecticut (CT) or New York (NY) product and wants to use a non-participating laboratory/pathologist or wants to provide the member with a form to obtain laboratory/pathology services outside the physician office.
Last Published 01.25.2022
Effective Date: 05.01.2020 – This policy addresses a participating provider's use of a non-participating provider physician, facility, or other healthcare provider in a member’s care, and the Member Advanced Notice Form.
Last Published 06.01.2021
Effective Date: 05.01.2020 – This policy addresses participating surgeons located in New York using non-participating assistant surgeons and co-surgeons for non-emergent procedures.
Last Published 06.01.2021
Effective Date: 05.01.2020 – This policy addresses participating providers in New York and Connecticut using non-participating providers for intraoperative neuro-monitoring (IONM).
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses patient lifts. Applicable Procedure Codes: E0621, E0625, E0630, E0635, E0636, E0639, E0640, E1035, E1036.
Last Published 01.25.2022
Effective Date: 07.01.2021 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Last Published 05.02.2022
Effective Date: 05.01.2022 – This policy addresses pediatric gait trainers, standing systems, and walkers. Applicable Procedure Codes: A4636, A4637, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158, E0159, E0637, E0638, E0641, E0642, E8000, E8001, E8002.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses pediatric outpatient intensive feeding programs. Applicable Procedure Code: 92526.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses percutaneous neuroablation for the treatment of severe cancer pain and trigeminal neuralgia. Applicable Procedure Codes: 64605, 64610, 64620, 64640.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke. Applicable Procedure Code: 93580.
Last Published 01.25.2022
Effective Date: 12.01.2021 – This policy addresses percutaneous vertebroplasty and kyphoplasty for treating spinal pain. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses the use of pharmacogenetic multi-gene panel testing for genetic polymorphisms. Applicable Procedure Codes: 0029U, 0078U, 0173U, 0175U, 0286U, 0290U, 0291U, 0292U, 0293U, 81479.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses physical, occupational, speech, and cognitive therapy, and therapeutic manipulation for New Jersey Small Group members.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses the use of cranial orthotic devices for treating infants following craniosynostosis surgery or for nonsynostotic (nonfusion) deformational or positional plagiocephaly. Applicable Procedure Codes: 21175, D5924, L0112, L0113, S1040.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses pneumatic and intermittent limb compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses power mobility devices.
Last Published 01.25.2022
Effective Date: 01.01.2021 – This policy addresses the process and timeframes for participating practitioner and provider administrative claims appeals brought on their own behalf.
Last Published 01.03.2022
Effective Date: 01.01.2022 – This policy addresses preimplantation genetic testing (PGT) and related services. Applicable Procedure Codes: 58970, 58974, 76948, 81228, 81229, 81349, 81479, 89250, 89251, 89253, 89254, 89255, 89258, 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89342, 89257, 89352, S4011, S4015, S4016, S4022, S4037.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses preimplantation genetic testing (PGT). Applicable Procedure Codes: 0254U, 81228, 81229, 81479.
Last Published 05.01.2022
Effective Date: 01.01.2022 – This policy addresses preventive care services.
Last Published 05.01.2022
Effective Date: 04.01.2022 – This policy addresses services which are exempt from the standard outpatient precertification requirement.
Last Published 01.25.2022
Effective Date: 07.01.2021 – This policy addresses private duty nursing (PDN) services. Applicable Procedure Code: T1000.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, G0460, G0465, M0076, P9020.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses prostrate surgeries and interventions, including transurethral ablation, cryoablation, surgical prostatectomy, prostatic urethral lift (PUL), high-energy water vapor thermotherapy, and transperineal placement of biodegradable material. Applicable Procedure Codes: 0421T, 0582T, 0655T, 37243, 52441, 52442, 53850, 53852, 53854, 53855, 55866, 55873, 55874.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses prosthetic devices, specialized/computerized/myoelectric limbs, and wigs, and includes applicable procedure codes for breast prosthesis, ear/eye/nose/facial prosthesis, lower and upper limb prosthetics, additions to upper extremity, prosthetic socks, repairs and replacements, and wigs.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses radiation therapy fractionation, image-guided radiation therapy (IGRT), and special radiation therapy services. Applicable Procedure Codes: 77014, 77331, 77370, 77385, 77386, 77387, 77399, 77401, 77402, 77407, 77412, 77470, 77520, 77522, 77523, 77525, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses radiology procedures which require precertification by eviCore healthcare, including computerized axial tomography (CAT) scan, CT colonography/virtual colonoscopy (for diagnostic purposes), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), nuclear medicine imaging, positron emission tomography (PET) scans, and obstetrical ultrasound.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses radiopharmaceuticals and contrast media administered by eviCore healthcare.
Last Published 05.01.2022
Effective Date: 04.01.2022 – This policy addresses referrals to a specialist, hospital, or ancillary provider.
Last Published 09.01.2020
Effective Date: 09.01.2020 – This policy addresses the review of in-network exception requests for members residing within Oxford's service area.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, septal dermatoplasty, and nasal polypectomy. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30560, 30620, 31237.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses routine foot care for members with diabetes or who are at risk for neurological or vascular disease arising from diseases such as diabetes.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses sacroiliac joint interventions, including sacroiliac joint injections and sacroiliac joint fusion. Applicable Procedure Codes: 27096, 27279, 27280, 64451, G0260.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses planned preventive screening colonoscopies performed in a hospital outpatient department. Applicable Procedures Codes: 45378, 45380, 45381, 45384, 45385, G0105, G0121.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses services requiring prior authorization and their related policies.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses a site of service differential that reduces practice expense payments for services provided in facility or ambulance settings.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses skilled care and custodial care services. Applicable Procedure Codes: 99509, S5100, S5101, S5102, S5105, S5120, S5121, S5125, S5126, S5130, S5131, S5135, S5136, S5140, S5141, S5150, S5151, S5170, S5175, S9125, T1005, T1019, T1020.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses skin and soft tissue substitutes.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses speech generating devices. Applicable Procedure Codes: E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599.
Last Published 01.25.2022
Effective Date: 05.01.2020 – This policy addresses speech therapy and early intervention/birth to three programs. Applicable Procedure Codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92610, 92626, 92627, 92700, G0153, H2014, H2015, H2019, S9128, S9152, T1015, T1023, T1024, T1025, T1026, T1027, T1028, T2024.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses spinal fusion enhancement products. Applicable Procedure Codes: 20930, 20931, 20939, 22899.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses stereotactic radiation therapy, including stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). Applicable Procedures Codes: 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77371, 77372, 77373, 77432, 77435, G0339, G0340.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses surgery of the ankle. Applicable Procedure Codes: 27685, 27700, 27702, 27703, 27704, 29891, 29892, 29894, 29895, 29897, 29898, 29899.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses surgery of the elbow. Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24366, 24370, 24371, 29830, 29834, 29837, 29838.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses surgery of the foot. Applicable Procedure Codes: 28285, 28289, 28291, 28292, 28295, 28297, 28298, 28299, 28296, 28299, 29893.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses surgery of the hand or wrist. Applicable Procedure Codes: 25280, 25332, 25441, 25442, 25443, 25444, 25445, 25446, 25447, 25449, 26530, 26531, 26535, 26536, 29840, 29843, 29844, 29845, 29846, 29847.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses surgery of the hip and femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 29860, 29861, 29862, 29863, 29914, 29915, 29916, 29999, S2118.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses surgery of the knee. Applicable Procedure Codes: 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889.
Last Published 05.02.2022
Effective Date: 05.01.2022 – This policy addresses surgery of the shoulder. Applicable Procedure Codes: 23470, 23472, 23473, 23474, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 36465, 36466, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses surgical treatment for spine pain.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the use of a sympathetic blockade using a local anesthetic. Applicable Procedure Codes: 64510, 64517, 64520, 64530.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20552, 20553, 20605, 20606, 21010, 21050, 21060, 21070, 21085, 21089, 21110, 21198, 21209, 21240, 21242, 21243, 21247, 21299, 21499, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, E1702.
Last Published 01.25.2022
Effective Date: 05.01.2021 – This policy addresses thermography, including digital infrared thermal imaging, temperature gradient studies, and magnetic resonance (MR) thermography. Applicable Procedure Codes: 76498, 93740.
Last Published 03.15.2022
Effective Date: 10.01.2021 – This policy addresses initial benefit administrative decision and notification timeframes.
Last Published 01.25.2022
Effective Date: 05.01.2020 – This policy addresses initial utilization management decision and notification timeframes.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899.
Last Published 01.25.2022
Effective Date: 11.01.2021 – This policy addresses the SynCardia™ temporary Total Artificial Heart. Applicable Procedure Codes: 33927, 33928, 33975, 33976, 33979, 33981, 33982, 33983, 33995, 33997.
Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 0646T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33370, 33418, 33419, 33477, 33999, 93799.
Last Published 04.01.2022
Effective Date: 04.01.2022 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses transcutaneous electrical nerve stimulator (TENS), including supplies and conductive garments. Applicable Procedure Codes: A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731, E0762, K1023.
Last Published 01.25.2022
Effective Date: 06.01.2021 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.
Last Published 01.25.2022
Effective Date: 07.01.2021 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.
Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 61886, 64553, 64568, 64570, E0770, E1399, K1016, K1017, K1020, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Last Published 02.01.2022
Effective Date: 02.01.2022 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Code: 0656T, 0657T, 22899.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses video electroencephalographic (EEG) monitoring and recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Last Published 01.25.2022
Effective Date: 01.01.2021 – This policy addresses the benefit and coverage considerations for vision services.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 0687T, 0688T, 0704T, 0705T, 0706T, 92065, 92499.
Last Published 03.01.2022
Effective Date: 03.01.2022 – This policy addresses vitamin D testing. Applicable Procedure Codes: 0038U, 82306, 82652.
Last Published 01.01.2022
Effective Date: 01.01.2022 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 97610, A6000, E0231, E0232.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses wheelchair options and accessories.
Last Published 05.01.2022
Effective Date: 05.01.2022 – This policy addresses wheelchair seating. Applicable Procedure Codes: E0953, E0955, E0956, E0957, E0960, E0966, E0992, E1028, E2231, E2291, E2292, E2293, E2294, E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2610, E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2619, E2620, E2621, E2622, E2623, E2624, E2625, K0108, K0669.
Last Published 04.01.2022
Effective Date: 03.01.2022 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0012U, 0013U, 0014U, 0036U, 0094U, 0212U, 0213U, 0214U, 0215U, 0265U, 81415, 81416, 81417, 81425, 81426, 81427.
Information regarding a policy or procedure that is not available online and copies of UnitedHealthcare Oxford Clinical and Administrative Policies can also be obtained by sending a written request to:
Oxford Policy Requests
4 Research Drive
Shelton, CT 06484
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