UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies

17-Alpha-Hydroxyprogesterone Caproate (Makena® and 17P) – Oxford Clinical Policy

Effective Date: 09.01.2020 – 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 – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 27299, 64625, 64633, 64634, 64635, 64636, 64999.

Abnormal Uterine Bleeding and Uterine Fibroids – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound ablation (MRgFUS), and ultrasound-guided radiofrequency ablation. Applicable Procedure Codes: 0071T, 0072T, 0404T, 37243, 58578, 58674, 58999, J7296, J7297, J7298, J7301, J7306, S4981.

Abortions (Therapeutic and Elective) – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses therapeutic and elective abortions. Applicable Procedure Codes: 59100, 59120, 59121, 59130, 59135, 59136, 59140, 59150, 59151, 59812, 59820, 59821, 59830, 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866, 59870, S0199, S2260, S2265, S2266, S2267.

Accreditation Requirements for Radiology Services

Effective Date: 06.01.2020 – This policy addresses accreditation requirements for radiologists, radiology centers, and multi-speciality provider groups interested in participating in the UnitedHealthcare Oxford network.

Acquired Rare Disease Drug Therapy Exception Process – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses the exception process for the experimental/investigational treatment (drug therapy) of an acquired rare disease.

Actemra® (Tocilizumab) Injection for Intravenous Infusion – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Actemra® (tocilizumab) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, systemic juvenile idiopathic arthritis, cytokine release syndrome, acute graft-versus-host disease, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J3262.

Acupuncture – Oxford Reimbursement Policy

Effective Date: 10.01.2020 – This policy addresses acupuncture services. Applicable Procedure Codes: 20560, 20561, 97014, 97032, 97810, 97811, 97813, 97814, A4212, A4215, G0283, S8930.

Adakveo® (Crizanlizumab-Tmca) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Adakveo® (crizanlizumab-tmca) to reduce the frequency of vasoocclusive crises in patients with sickle cell disease. Applicable Procedure Code: J0791.

Add-On Policy – Oxford Reimbursement Policy

Effective Date: 08.01.2020 – This policy addresses add-on codes for supplemental services, including Mohs micrographic surgery, psychological and neuropsychological testing, and critical care services. Applicable Procedure Codes: 17311, 17312, 17313, 17314, 17315, 96136, 96137, 96138, 96139, 99291, 99292.

Advanced Practice Health Care Provider – Oxford Reimbursement Policy

Effective Date: 03.01.2021 – This policy addresses reporting services of Advanced Practice Health Care Professionals, within a medical or other healthcare practice, to ensure submitted medical claims accurately identify the provider of service, including non-physician health care professionals.

After Hours and Weekend Care – Oxford Administrative Policy

Effective Date: 05.01.2020 – This policy addresses procedure codes for after hours and weekend care services. Applicable Procedure Codes: 99050, 99051, 99053, 99056, 99058, 99060.

Airway Clearance Devices – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses airway clearance devices, such as high-frequency chest wall oscillation systems, acoustical or mechanical percussor, positive expiratory pressure and aerosol drug delivery system combination device, and intrapulmonary percussive ventilation (IPV) devices. Applicable Procedure Codes: A7025, A7026, E0481, E0483, E1399.

Alpha1-Proteinase Inhibitors – Oxford Clinical Policy

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 Policy – Oxford Reimbursement Policy

Effective Date: 04.19.2021 – This policy addresses services included as part of an ambulance transportation service, ambulance modifier usage, provider specialty reporting ambulance services, and the requirements for reporting Advanced Life Support: Level 2 (ALS2) ambulance transportation.

Ambulance Services – Oxford Administrative Policy

Effective Date: 05.01.2021 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.

Amondys 45™ (Casimersen) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Amondys 45™ (casimersen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Codes: C9399, J3490, and J3590.

Anesthesia (CES) – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses procedural or pain management services that are an integral part of anesthesia services, as well as anesthesia services that are an integral part of procedural services.

Apheresis – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.

Articular Cartilage Defect Repairs – Oxford Clinical Policy

Effective Date: 05.01.2021 – 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.

Assignment of Benefits and Balance Billing

Effective Date: 06.01.2020 – This policy addresses assignment of benefits for services rendered by non-network providers and balance billing.

Assistant-at-Surgery – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses services performed by an assistant for a physician performing a surgical procedure.

Assisted Administration of Clotting Factors, Coagulant Blood Products & Other Hemostatics – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses assisted administration of clotting factors and coagulant blood products, including home health care services.

Athletic Pubalgia Surgery – Oxford Clinical Policy

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 – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses home sleep apnea testing, attended full-channel nocturnal polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, and attended PAP titration. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.

Autism – Oxford Administrative Policy

Effective Date: 10.01.2020 – This policy addresses services for the treatment of autism.

Autologous Cellular Therapy for Certain Indications

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

B Bundle Codes (CES) – Oxford Reimbursement Policy

Effective Date: 11.01.2020 – This policy addresses procedure codes assigned a "B" status indicator on the National Physician Fee Schedule (NPFS) by the Centers for Medicare and Medicaid Services (CMS).

Balloon Sinus Ostial Dilation – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298, 31299

Bariatric Surgery – Oxford Clinical Policy

Effective Date: 12.01.2020 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, sleeve gastrectomy, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.

Beds and Mattresses – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses hospital beds, mattresses, and accessories. Applicable Procedure Codes: E0193, E0194, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0270, E0271, E0272, E0273, E0274, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0305, E0310, E0315, E0316, E0328, E0329, E0462, E0910, E0911, E0912, E0940.

Behavioral Health Services – Oxford Administrative Policy

Effective Date: 01.01.2021 – This policy addresses behavioral health services for the treatment of mental health and substance use disorders.

Benlysta® (Belimumab) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Benlysta® (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN). Applicable Procedure Code: J0490.

Bilateral Procedures (CES) – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses unilateral procedures that can be performed on both sides of the body during the same session by the same individual physician or other qualified health care professional, including procedure codes with bilateral in their intent or "bilateral" in the description.

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair – Oxford Clinical Policy

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).

Bone or Soft Tissue Healing and Fusion Enhancement Products – Oxford Clinical Policy

Effective Date: 09.01.2020 – 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.

Botulinum Toxins A and B – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Applicable Procedure Codes: J0585, J0586, J0587, J0588.

Breast Imaging for Screening and Diagnosing Cancer – Oxford Clinical Policy

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 and Poland Syndrome – Oxford Clinical Policy

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 – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.

Breast Repair/Reconstruction Not Following Mastectomy – Oxford Clinical Policy

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) – Oxford Clinical Policy

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 – Oxford Clinical Policy

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

Buprenorphine (Probuphine® & Sublocade®) – Oxford Clinical Policy

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 – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272, 93285, 93291, 93298, E0616, G2066.

Cardiology Procedures Requiring Prior Authorization for eviCore healthcare Arrangement – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses cardiology procedures requiring precertification with initial review performed by eviCore healthcare.

Cardiovascular Disease Risk Tests – Oxford Clinical Policy

Effective Date: 03.01.2021 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0052U, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.

Care Plan Oversight – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses care plan oversight services as part of physician or other health care professional supervision of patients under the care of home health agencies, hospice, or nursing facilities.

Carrier Testing for Genetic Diseases – Oxford Clinical Policy

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.

Catheter Ablation for Atrial Fibrillation – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses catheter ablation for atrial fibrillation. Applicable Procedure Codes: 93653, 93655, 93656, 93657.

Cell-Free Fetal DNA Testing – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0168U, 81420, 81422, 81479, 81507.

Chelation Therapy for Non-Overload Conditions – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.

Chemosensitivity and Chemoresistance Assays in Cancer – Oxford Clinical Policy

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) – Oxford Clinical Policy

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) – Oxford Clinical Policy

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.

Claims Recovery – Oxford Administrative Policy

Effective Date: 01.01.2021 – This policy addresses recovery of claim overpayments.

Clinical Laboratory Improvement Amendments (CLIA) ID Requirement (CES) – Oxford Reimbursement Policy

Effective Date: 07.01.2020 – This policy addresses laboratory services under the Clinical Laboratory Improvement Amendment (CLIA) 1988 statute and regulations.

Clinical Review – Oxford Administrative Policy

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.

Clinical Trials – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.

Clotting Factors, Coagulant Blood Products & Other Hemostatics – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses clotting factors and coagulant blood products. Applicable Procedure Codes: J7170, J7175, J7177, J7178, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7192, J7193, J7194, J7195, J7198, J7199, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7212.

Co-Surgeon/Team Surgeon (CES) – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses co-surgeon and team surgeon services.

Cochlear Implants – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.

Collagen Crosslinks and Biochemical Markers of Bone Turnover – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.

Complement Inhibitors (Soliris® & Ultomiris®) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Soliris® (eculizumab) and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: J1300, J1303.

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures – Oxford Clinical Policy

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 Procedures Codes: 0054T, 0055T, 20985.

Computerized Dynamic Posturography – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.

Consultation Services – Oxford Reimbursement Policy

Effective Date: 05.01.2021 – This policy addresses consultation services. Applicable Procedure Codes: 99446, 99447, 99448, 99449, 99451, 99452, G0406, G0407, G0408, G0425, G0426, G0427, G0508, G0509.

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4211, A4226, A9274, A9276, A9277, A9278, E0784, E0787, E1399, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.

Contraceptives – Oxford Administrative Policy

Effective Date: 09.01.2020 – This policy addresses contraceptive procedures/appliances/devices and injectable drugs provided in a physician’s office.

Coordination of Benefits – Oxford Administrative Policy

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.

Core Decompression for Avascular Necrosis – Oxford Clinical Policy

ffective 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 – Oxford Clinical Policy

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 – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses cosmetic and reconstructive procedures.

Credentialing Guidelines: Participation in the eviCore healthcare Network

Effective Date: 02.01.2020 – This policy addresses credentialing guidelines for radiologists and cardiologists interested in participating in the eviCore healthcare network.

Crysvita® (Burosumab-Twza) – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of Crysvita® (burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH) and Fibroblast Growth Factor 23 (FGF23)-related hypophosphatemia in tumor-induced osteomalacia (TIO). Applicable Procedure Code: J0584.

Cytological Examination of Breast Fluids for Cancer Screening – Oxford Clinical Policy

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.

Deep Brain and Cortical Stimulation – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses conventional deep brain stimulation and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.

Denosumab (Prolia® & Xgeva®) – Oxford Clinical Policy

Effective Date: 10.01.2020 – This policy addresses the use of denosumab (Prolia® & Xgeva®). Applicable Procedure Code: J0897.

Dental and Oral Surgical Procedures – Oxford Administrative Policy

Effective Date: 04.01.2021 – This policy addresses oral surgical and dental procedures and related anesthesia when determined to be medical in nature.

Device, Implant, and Skin Substitute Policy (CES) – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses coding guidelines associated with reporting devices, implants, and skin substitutes with their associated procedures for outpatient hospital services.

Diabetes Supply Coverage – Oxford Clinical Policy

Effective Date: 10.01.2020 – This policy addresses supplies, medications, and equipment for the treatment of diabetes. Applicable Procedure Codes: A4206, A4210, A4212, A4215, A4230, A4231, A4232, A4233, A4234, A4235, A4236, A4244, A4245, A4250, A4252, A4253, A4255, A4256, A4258, A4259, A6257, A9275, E0607, E2100, E2101, J1610, J1815, J1817, J3490, K0601, K0602, K0603, K0604, K0605, S5550, S5551, S5552, S5553, S5560, S5561, S5565, S5566, S5570, S5571, S8490.

Dialysis Services – Oxford Administrative Policy

Effective Date: 03.01.2021 – 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.

Disclosure Policy – Oxford Administrative Policy

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.

Discogenic Pain Treatment – Oxford Clinical Policy

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.

Discontinued Procedure (CES) – Oxford Reimbursement Policy

Effective Date: 07.01.2020 – This policy addresses surgical and diagnostic procedures terminated at the direction of a health care professional, including the use of modifier 53 (discontinued procedure).

Drug Coverage Criteria - New and Therapeutic Equivalent Medications – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses medications for which certain types of prescription drug benefit exclusions may apply.

Drug Coverage Guidelines – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses multiple drug coverage guidelines.

Drug Testing – Oxford Reimbursement Policy

Effective Date: 07.01.2020 – This policy addresses the daily limit for presumptive and definitive drug testing, and specimen validity testing.

Durable Medical Equipment, Orthotics and Prosthetics (CES) – Oxford Reimbursement Policy

Effective Date: 04.19.2021 – This policy addresses rental and/or purchase of certain items of durable medical equipment (DME), prosthetics, and orthotics.

Durable Medical Equipment, Orthotics, Medical Supplies and Repairs/Replacements – Oxford Administrative Policy

Effective Date: 05.01.2021 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.

Elbow Replacement Surgery (Arthroplasty) – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.

Elective Inpatient Services – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.

Electric Tumor Treatment Field Therapy – Oxford Clinical Policy

Effective Date: 03.01.2021 – 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 – Oxford Clinical Policy

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 – Oxford Clinical Policy

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 – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses electrical stimulation and electromagnetic therapy for wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Applicable Procedure Codes: 0278T, 63650, 63655, 63663, 63664, 63685, 64566, 64999, E0744, E0745, E0762, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.

Electroencephalographic (EEG) Monitoring and Video Recording – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.

Eloctate™ [Antihemophilic Factor (Recombinant), FC Fusion Protein] for Connecticut Lines of Business – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Eloctate™ [antihemophilic factor (recombinant), FC fusion protein] for the treatment of Hemophilia A. Applicable Procedure Codes: J7199, J7205.

Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.

Emergency Department (ED) Facility Evaluation and Management (E&M) Coding (CES) – Oxford Reimbursement Policy

Effective Date: 03.01.2021 – This policy addresses level 4 and level 5 evaluation and management (E/M) codes when billed for services rendered in an emergency department. Applicable Procedures Codes: 99284, 99285, 99291, 99292, G0383, G0384.

Emergency Room Visits (Including Coverage for Members Outside of the United States) – Oxford Administrative Policy

Effective Date: 09.01.2020 – This policy addresses emergency room visits, including services provided outside of the United States.

Entyvio® (Vedolizumab) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Entyvio® (vedolizumab) for the treatment of Crohn's disease, ulcerative colitis, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J3380.

Enzyme Replacement Therapy – Oxford Clinical Policy

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 (elosulfase alfa). Applicable Procedure Codes: J0180, J0221, J1322, J1458, J1743, J1931, J2840, J3397, J3590.

Epidural Steroid Injections for Spinal Pain – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses epidural steroid injections for spinal pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484.

Epiduroscopy, Epidural Lysis of Adhesions and Discography – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses functional anesthetic discography (FAD), provocative discograph,y epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions for the diagnosis or treatment of any type of neck, back, or spinal disorder. Applicable Procedure Codes: 62263, 62264, 62290, 62290, 64999, 72285, 72295.

Erythropoiesis-Stimulating Agents – Oxford Clinical Policy

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.

Evaluation and Management (E/M) – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses evaluation and management (E/M) services.

Evenity® (Romosozumab-Aqqg) – Oxford Clinical Policy

Effective Date: 12.01.2020 – This policy addresses the use of Evenity® (romosozumab- aqqg) for the treatment of osteoporosis in postmenopausal patients at high risk for fracture. Applicable Procedures Code: J3111.

Evkeeza™ (Evinacumab-dgnb) – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of Evkeeza (evinacumab-dgnb) for the treatment of homozygous familial hypercholesterolemia (HoFH). Applicable Procedure Codes: C9399, J3490, J3590.

Exondys 51® (Eteplirsen) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.

Experimental/Investigational Treatment for NJ Plans – Oxford Administrative Policy

Effective Date: 09.01.2020 – This policy addresses experimental and/or investigational treatment or procedures for New Jersey (NJ) Plans.

Experimental/Investigational Treatment – Oxford Administrative Policy

Effective Date: 09.01.2020 – This policy addresses experimental and/or investigational treatment or procedures.

Extended Benefits for Total Disability & Succeeding Carrier for Inpatient Admissions

Effective Date: 12.01.2019 – This policy addresses extended benefits for totally disabled members, including when a member changes carriers while confined in an inpatient facility.

Extracorporeal Shock Wave Therapy (ESWT) For Musculoskeletal Conditions and Soft Tissue Wounds – Oxford Clinical Policy

Effective Date: 08.01.2020 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.

Facet Joint Injections for Spinal Pain – Oxford Clinical Policy

Effective Date: 05.01.2021 – 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.

Fecal Calprotectin Testing – Oxford Clinical Policy

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

Filing Deadlines for Claims Submissions

Effective Date: 12.01.2019 – This policy addresses timeframes for submission of original claims, additional information, and appeals.

Follicle Stimulating Hormone (FSH) Gonadotropins – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses follicle stimulating hormone (FSH) gonadotropins, including Gonal-f/Gonal-f RFF (follitropin alfa) and Follistim AQ (follitropin beta). Applicable Procedure Codes: S0126, S0128, S4042.

Follow-Up Care Rendered in an Emergency Room Site of Service – Oxford Administrative Policy

Effective Date: 10.01.2020 – This policy addresses follow-up care when rendered in an emergency room (ER) site of service/setting.

Formula and Specialized Food – Oxford Administrative Policy

Effective Date: 03.01.2021 – 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, S9433, S9434, S9435, T2101.

From - To Date Policy – Oxford Reimbursement Policy

Effective Date: 04.19.2021 – This policy addresses the "from" and "to" dates reported on claims.

Functional Endoscopic Sinus Surgery (FESS) – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.

Gamifant® (Emapalumab-Lzsg) – Oxford Clinical Policy

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.

Gastrointestinal Motility Disorders, Diagnosis and Treatment – Oxford Clinical Policy

Effective Date: 09.01.2020 – 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 – Oxford Clinical Policy

Effective Date: 03.01.2021 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 0097U, 87505, 87506, 87507.

Gender Dysphoria Treatment – Oxford Clinical Policy

Effective Date: 03.01.2021 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.

Genetic Testing for Cardiac Disease – Oxford Clinical Policy

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 – Oxford Clinical Policy

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 – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 0216U, 0217U, 81440, 81460, 81465, 81479.

Genitourinary Pathogen Nucleic Acid Detection Panel Testing – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses genitourinary pathogen nucleic acid detection panel testing to evaluate symptomatic women for vaginitis. Applicable Procedure Codes: 0068U, 87480, 81513, 81514, 87481, 87482, 87510, 87511, 87512, 87660, 87661, 87797, 87798, 87799, 87800, 87801.

Givlaari® (Givosiran) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.

Glaucoma Surgical Treatments – Oxford Clinical Policy

Effective Date: 09.01.2020 – 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.

Global Days – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses the timeframe (global days) that applies to certain procedures subject to a global surgical package concept whereby all necessary services normally furnished by a physician (before, during, and after the procedure) are included in the reimbursement for the procedure performed.

Gonadotropin Releasing Hormone Analogs – Oxford Clinical Policy

Effective Date: 03.01.2021 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products. Applicable Procedure Codes: J1950, J3315, J3316, J9155, J9202, J9217, J9225, J9226.

Gynecomastia Treatment – Oxford Clinical Policy

Effective Date: 05.01.2021 – 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 – Oxford Clinical Policy

Effective Date: 03.01.2021 – 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.

Hereditary Angioedema (HAE), Treatment and Prophylaxis – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of C1 esterace inhibitors (human), C1 esterace inhibitors (recombinant), and plasma kallikrein inhibitors (human) for the treatment and prophlaxis of hereditary angioedema (HAE). Applicable Procedure Codes: J0596, J0597, J0598, J1290.

Home Health Care – Oxford Clinical Policy

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

Home Hemodialysis – Oxford Clinical Policy

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.

Home Traction Therapy

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

Hospital Based Ambulance (CES) – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses services included as part of an ambulance transportation service and ambulance modifier usage. Applicable Procedure Codes: A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436.

Human Menopausal Gonadotropins (hMG) – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses human menopausal gonadotropins (hMG), including Menopur® (menotropins for injection). Applicable Procedure Codes: S0122, S4042.

Hysterectomy – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.

Ilaris® (Canakinumab) – Oxford Clinical Policy

Effective Date: 11.01.2020 – 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) – Oxford Clinical Policy

Effective Date: 02.01.2021 – 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) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, J1459, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599.

Immune Globulin - Site of Care – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses hospital outpatient facility infusion services for intravenous immune globulin (IVIG) and subcutaneous immune globulin (SCIG) therapy. Applicable Procedure Codes: J1459, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599, J3590.

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors – Oxford Clinical Policy

Effective Date: 09.01.2020 – 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 – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses implanted electrical stimulator for spinal cord. Applicable Procedure Codes: 63650, 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.

In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy – Oxford Administrative Policy

Effective Date: 01.01.2021 – 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.

In-Office Laboratory Testing and Procedures List – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses laboratory testing/procedures that Oxford Network physicians may provide in their offices, including specimen handling and venipuncture.

Increased Procedural Services (CES) – Oxford Reimbursement Policy

Effective Date: 06.01.2020 – This policy addresses services provided by a health care professional that are substantially greater than typically required for the services, including the use of modifiers 22 (increased procedural service) and 63 (procedure performed on infants less than 4 kilograms).

Infertility Diagnosis and Treatment – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses diagnostic and therapeutic procedures for infertility and cryopreservation.

Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of infliximab products, including Avsola™ (infliximab-axxq), Inflectra® (infliximab-dyyb), Remicade® (infliximab), and Renflexis® (infliximab-abda). Applicable Procedure Codes: J1745, Q5103, Q5104, Q5109, Q5121.

Inhaled Nitric Oxide for Infants – Oxford Clinical Policy

Effective Date: 03.01.2021 – This policy addresses the use of inhaled nitric oxide (iNO) for treating term or near-term infants with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN). Applicable Procedure Code: 94799.

Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines – Oxford Clinical Policy

Effective Date: 10.01.2020 – 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.

Injection and Infusion Services (CES) – Oxford Reimbursement Policy

Effective Date: 04.19.2021 – This policy addresses therapeutic and diagnostic injection and infusion services when reported with evaluation and management (E/M) services, including related supplies and/or drugs.

Inpatient Maternity Stay and Subsequent Home Nursing – Oxford Administrative Policy

Effective Date: 12.01.2019 – This policy addresses the state mandated length of inpatient stay for mother and baby following delivery and subsequent home nursing visits.

Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Effective Date: 09.01.2020 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.

Intraoperative Neuromonitoring – Oxford Reimbursement Policy

Effective Date: 05.01.2021 – This policy addresses intraoperative neuromonitoring (IONM) services. Applicable Procedure Codes: 92653, 95822, 95860, 95861, 95863 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95925, 95926, 95927, 95928, 95929, 95930, 95933, 95937, 95938, 95939, 95940, G0453.

Intrauterine Fetal Surgery – Oxford Clinical Policy

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.

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of intravenous enzyme replacement drug products for the treatment of Gaucher disease, including Cerezyme® (imiglucerase), Elelyso® (taliglucerase), and VPRIV® (velaglucerase). Applicable Procedure Codes: J1786, J3060, J3385.

Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) – Oxford Clinical Policy

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.

Knee Replacement Surgery (Arthroplasty), Total and Partial – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.

Krystexxa® (Pegloticase) – Oxford Clinical Policy

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 – Oxford Clinical Policy

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

Lemtrada (Alemtuzumab) – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of Lemtrada (alemtuzumab) for treatment of relapsing forms of multiple sclerosis. Applicable Procedure Code: J0202.

Light and Laser Therapy – Oxford Clinical Policy

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 – Oxford Clinical Policy

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 – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses lower extremity vascular angiography and endovascular revascularization procedures. Applicable Procedure Codes: 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235, 75710, 75716.

Luxturna™ (Voretigene Neparvovec-Rzyl) – Oxford Clinical Policy

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.

Lyme Disease – Oxford Clinical Policy

Effective Date: 12.01.2020 – This policy addresses the use of parenteral antibiotics for treating Lyme disease. Applicable Procedure Codes: J0558, J0561, J0696, J0698, J2510, J2540.

Macular Degeneration Treatment Procedures – Oxford Clinical Policy

Effective Date: 09.01.2020 – 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.

Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan – Site of Service – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses advanced radiologic imaging procedures performed in a hospital outpatient department.

Manipulation Under Anesthesia – Oxford Clinical Policy

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.

Manipulative Therapy – Oxford Clinical Policy

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

Manual Wheelchairs – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses manual wheelchairs.

Maximum Dosage and Frequency – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.

Maximum Frequency Per Day Policy (CES) – Oxford Reimbursement Policy

Effective Date: 04.19.2021 – This policy addresses maximum frequency per day determinations for services/procedures.

Mechanical Stretching Devices – Oxford Clinical Policy

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.

Member Administrative Grievance & Appeal (Non UM) Process & Timeframes

Effective Date: 12.01.2019 – This policy addresses the process and timeframes of an administrative grievance/appeal.

Meniscus Implant and Allograft – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.

Microsurgery (CES) – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses use of an operating microscope during a surgical procedure. Applicable Procedure Codes: 64727, 69990.

Mifeprex® (Mifepristone) – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of Mifeprex® (mifepristone) in combination with misoprostol for medical termination of intrauterine pregnancy. Applicable Procedure Codes: S0190, S0191.

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) and Achalasia – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD) and the Per Oral Endoscopic Myotomy (POEM) procedure for achalasia or diffuse esophageal spasm. Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43499, 43999.

Modifier Reference (CES) – Oxford Reimbursement Policy

Effective Date: 06.01.2020 – This policy addresses other reimbursement policies in which modifiers are addressed.

Modifier SU – Oxford Reimbursement Policy

Effective Date: 04.01.2020 – This policy addresses reimbursement for claims appended with modifier SU.

Mohs Micrographic Surgery – Oxford Reimbursement Policy

Effective Date: 06.01.2020 – This policy addresses Mohs micrographic surgery, including excision and pathology services. Applicable Procedure Codes: 17311, 17312, 17313, 17314, 17315.

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.

Motorized Spinal Traction

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

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures – Oxford Reimbursement Policy

Effective Date: 04.01.2021 – This policy addresses when multiple diagnostic cardiovascular procedures or diagnostic ophthalmology procedures are performed on the same day.

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging – Oxford Reimbursement Policy

Effective Date: 02.01.2021 – This policy addresses multiple procedure payment reduction (MPPR) when multiple diagnostic imaging procedures are performed in a single session.

Multiple Procedures Payment Reduction (MPPR) for Medical and Surgical Services – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses multiple medical or surgical procedures performed on the same day by the same group physician and/or other health care professional.

Negative Pressure Wound Therapy – Oxford Clinical Policy

Effective Date: 03.01.2021 – 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 – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy . Applicable Procedure Codes: 55899, 64999.

Neurophysiologic Testing and Monitoring – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses nerve conduction studies and other neurophysiological testing.

Neuropsychological Testing Under the Medical Benefit – Oxford Clinical Policy

Effective Date: 01.01.2021 – 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.

New Patient Visit Policy – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses new patient visits. Applicable Procedure Codes: 92002, 92004, 99202, 99203, 99204, 99205, 99324, 99325, 99326, 99327, 99328, 99341, 99342, 99343, 99344, 99345, 99381, 99382, 99383, 99384, 99385, 99386, 99387, G0245, G0438, S0610, S0620.

Newborns

Effective Date: 03.01.2020 – This policy addresses enrollment and coverage of newborns.

Nonphysician Health Care Codes – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses nonphysician health care professional service codes. Applicable Procedure Codes: 96040, 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171, 97802, 97803, 97804, 98960, 98961, 98962, 99605, 99606, 99607, G0270, G0271, G2251.

Nonphysician Health Care Professionals Billing Evaluation and Management Codes – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses evaluation and management (E/M) services reported by nonphysician health care professionals.

Observation and Discharge – Oxford Reimbursement Policy

Effective Date: 04.01.2021 – This policy addresses observation care services and discharge day management. Applicable Procedure Codes: 99217, 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, 99236, 99238, 99239.

Observation Services – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses observation services in a hospital setting.

Obstetrical Policy – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses global obstetrical (OB) codes and itemization of maternity care services. Applicable Procedure Codes: 59400, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59525, 59610, 59612, 59614, 59618, 59620, 59622, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99417, G2212, S0273, S0274.

Obstetrical Ultrasonography – Oxford Clinical Policy

Effective Date: 01.01.2021 – 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.

Obstructive Sleep Apnea Treatment – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0466T, 0467T, 0468T, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, E0485, E0486, K1001, L8679, L8680, L8686, S2080, S2900.

Occipital Neuralgia and Headache Treatment – Oxford Clinical Policy

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.

Ocrevus® (Ocrelizumab) – Oxford Clinical Policy

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

Off-Label/Unproven Specialty Drug Treatment – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.

Office Based Procedures – Site of Service – Oxford Clinical Policy

Effective Date: 01.01.2021 – 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, 11406, 11422, 11426, 11442, 19000, 27096, 31579, 57460, 62270, 62321, 64479, 64490, 64493, 64633, 64635.

Omnibus Codes – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses multiple services/procedures.

Once in a Lifetime Procedures – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses certain procedures reimbursed only once during a patient’s lifetime.

One or More Sessions (CES) – Oxford Reimbursement Policy

Effective Date: 06.01.2020 – This policy addresses codes reimbursed only once during the defined treatment period. Applicable Procedure Codes: 61796, 61798, 62263, 62264, 63620, 66762, 66821, 66840, 67031, 67141, 67145, 67208, 67210, 67218, 67220, 67229.

Onpattro® (Patisiran) – Oxford Clinical Policy

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.

Orencia® (Abatacept) Injection for Intravenous Infusion – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Orencia® (abatacept) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, psoriatic arthritis, chronic graft-versus-host disease, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J0129.

Orthognathic (Jaw) Surgery – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses orthognathic (jaw) surgery.

Orthopedic Services – Oxford Administrative Policy

Effective Date: 05.01.2021 – This policy addresses services subject to utilization review with OrthoNet’s orthopedic division.

Otoacoustic Emissions Testing – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses neonatal hearing screening, auditory screening, and diagnostic testing using otoacoustic emissions (OAEs). Applicable Procedure Codes: 92558, 92587, 92588.

Outpatient Hospital Add-On Codes (CES) – Oxford Reimbursement Policy

Effective Date: 10.01.2020 – This policy addresses add-on codes when used to bill for services rendered at an outpatient hospital.

Outpatient Hospital Blood and Blood Products (CES) – Oxford Reimbursement Policy

Effective Date: 12.01.2020 – This policy addresses outpatient blood and blood products, including transfusion, irradiation, freezing, thawing, and splitting services, and packed red blood cells and whole blood. Applicable Procedures Codes: 86945, 86985, P9011.

Outpatient Hospital CCI Editing (CES) – Oxford Reimbursement Policy

Effective Date: 10.01.2020 – This policy addresses National Correct Coding Initiative (NCCI) edits not otherwise addressed in other reimbursement policies in order to determine whether CPT and/or HCPCS codes reported together by the outpatient hospital for the same member on the same date of service are eligible for separate reimbursement.

Outpatient Hospital Maximum Frequency Per Day Policy (CES) - Oxford Reimbursement Policy

Outpatient Hospital Observation (CES) – Oxford Reimbursement Policy

Effective Date: 12.01.2020 – This policy addresses outpatient hospital observation services. Applicable Procedures Codes: G0378, G0379.

Outpatient Medical Visits (CES) – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses outpatient medical visits when submitted in addition to other procedure codes, when in circumstances when multiple medical visit codes are submitted, and when trauma activation occurs in addition to critical care services.

Outpatient Physical and Occupational Therapy – Oxford Clinical Policy

Effective Date: 10.01.2020 – This policy addresses outpatient physical and occupational therapy services managed by OptumHealth Care Solutions.

Outpatient Surgical Procedures – Site of Service – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses the medical necessity of certain planned surgical procedures when performed in a hospital outpatient department.

Oxford's Outpatient Imaging Self-Referral – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses self-referral for outpatient imaging services.

Oxlumo™ (Lumasiran) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Oxlumo™ (Lumasiran) for the treatment of primary hyperoxaluria type 1 (PH1). Applicable Procedures Codes: C9074, J3490, J3590.

Panniculectomy and Body Contouring Procedures – Oxford Clinical Policy

Effective Date: 11.01.2020 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.

Parsabiv® (Etelcalcetide) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.

Participating Gastroenterologists Using Non-Participating Anesthesiologists: In-Office and Ambulatory

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).

Participating Provider Laboratory and Pathology Protocol – Oxford Administrative Policy

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.

Participating Providers Using Non-Participating Providers Protocol

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.

Participating Surgeons Using Non-Participating Assistant Surgeons and Co-Surgeons Protocol

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.

Participating Surgeons Using Non-Participating Providers for Intraoperative Neuro-Monitoring (IONM) Protocol

Effective Date: 05.01.2020 – This policy addresses participating providers in New York and Connecticut using non-participating providers for intraoperative neuro-monitoring (IONM).

Patient Lifts – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses patient lifts. Applicable Procedure Codes: E0621, E0625, E0630, E0635, E0636, E0639, E0640, E1035, E1036.

Pectus Deformity Repair – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.

Pediatric and Neonatal Critical and Intensive Care Services – Oxford Reimbursement Policy

Effective Date: 07.01.2020 – This policy addresses pediatric and neonatal critical and intensive care services. Applicable Procedure Codes: 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, 99480.

Pediatric Gait Trainers, Standing Systems, and Walkers – Oxford Clinical Policy

Effective Date: 05.01.2021 – 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.

Pediatric Outpatient Intensive Feeding Programs – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses pediatric outpatient intensive feeding programs. Applicable Procedure Code: 92526.

Percutaneous Patent Foramen Ovale (PFO) Closure – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke. Applicable Procedure Code: 93580.

Percutaneous Vertebroplasty and Kyphoplasty – Oxford Clinical Policy

Effective Date: 12.01.2020 – This policy addresses percutaneous vertebroplasty and kyphoplasty for treating spinal pain. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515.

Pharmacogenetic Testing

Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction – Oxford Reimbursement Policy

Effective Date: 02.01.2021 – This policy addresses reimbursement for the Practice Expense (PE) portions of certain therapy procedures when those services are the secondary or subsequent procedures provided on a single date of service by the same group physician and/or other health care professional.

Physical Medicine & Rehabilitation: PT, OT, and Evaluation & Management – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses physical and occupational therapy evaluation services and the use of the GO, GP, CO, and CQ modifiers.

Physical Medicine & Rehabilitation: Speech Therapy – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses CPT codes from the Physical Medicine and Rehabilitation, Evaluation and Management, Adaptive Behavior Assessment and other sections of the CPT Manual that will not be reimbursed when reported by Speech-Language Therapists/Pathologists.

Physical, Occupational, and Speech Therapy including Cognitive/Neuropsychological Rehabilitation for New Jersey Small Group Members – Oxford Clinical Policy

Effective Date: 10.01.2020 – This policy addresses physical, occupational, speech, and cognitive therapy, and therapeutic manipulation for New Jersey Small Group members.

Physician Extenders – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses physician extender eligibility for reimbursement of surgical and non-surgical services.

Plagiocephaly and Craniosynostosis Treatment – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of cranial orthotic devices for treating infants following craniosynostosis surgery or for nonsynostotic (nonfusion) deformational or positional plagiocephaly. Applicable Procedure Codes: 21175, D5924, L0112, L0113, S1040.

Pneumatic Compression Devices – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.

Power Mobility Devices – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses power mobility devices.

Practitioner/Provider Administrative Claim Reconsideration and Appeal Process – Oxford Administrative Policy

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.

Preimplantation Genetic Testing – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses preimplantation genetic testing (PGT). Applicable Procedure Codes: 81228, 81229, 81479.

Preventive Care Services – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses preventive care services.

Preventive Medicine and Screening (CES) – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses preventive medicine and screening services.

Prior Authorization Exemptions for Outpatient Services – Oxford Administrative Policy

Effective Date: 04.01.2021 – This policy addresses services which are exempt from the standard outpatient precertification requirement.

Private Duty Nursing (PDN) Services – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses private duty nursing (PDN) services. Applicable Procedure Code: T1000.

Procedure and Place of Service – Oxford Reimbursement Policy

Effective Date: 04.19.2021 – This policy addresses procedure codes that include the place of service (POS) in their description or where coding guidelines are provided relative to POS.

Procedure to Modifier Policy (CES) – Oxford Reimbursement Policy

Effective Date: 10.01.2020 – This policy addresses the appropriate use of modifiers with individual CPT and HCPCS procedure codes.

Professional/Technical Component (CES) – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses services with professional and/or technical component indicators, as well as information pertaining to duplicate/repeat services, modifier usage, services based on place of service (POS), and the professional component with an evaluation and management service.

Prolonged Services – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses prolonged services when reported in conjunction with companion evaluation and management (E/M) codes or other services. Applicable Procedure Codes: 99354, 99355, 99356, 99357, 99358, 99359, 99415, 99416, 99417, 99484, 99487, 99489, 99490, 99491, 99492, 99493, 99494, 99495, 99496, G0513, G0514, G2211, G2212.

Prolotherapy and Platelet Rich Plasma Therapies – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, 0481T, G0460, M0076, P9020, S9055.

Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs – Oxford Clinical Policy

Effective Date: 04.01.2021 – 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.

Provider Administered Drugs – Site of Care – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses outpatient hospital facility-based intravenous medication infusion. Applicable Procedure Codes: C9399, J0129, J0180, J0221, J0222, J0223, J0256, J0257, J0490, J0584, J0638, J0717, J0791, J0896, J1300, J1301, J1303, J1322, J1427, J1428, J1429, J1458, J1602, J1743, J1745, J1746, J1786, J1931, J2840, J3032, J3060, J3241, J3245, J3262, J3357, J3358, J3380, J3385, J3397, J3490, Q5103, Q5104, Q5121.

Radiation Therapy Procedures Requiring Prior Authorization for eviCore healthcare Arrangement – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses radiation therapy services which require precertification by eviCore healthcare.

Radicava® (Edaravone) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Radicava® (edaravone) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.

Radiology Procedures Requiring Precertification for eviCore healthcare Arrangement – Oxford Clinical Policy

Effective Date: 01.01.2021 – 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.

Radiopharmaceuticals and Contrast Media – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses radiopharmaceuticals and contrast media administered by eviCore healthcare.

Reblozyl® (Luspatercept-Aamt) – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses Reblozyl® (luspatercept-aamt) for the treatment of anemia in adult patients with beta thalassemia and symptomatic anemia in patients with myelodysplastic sydromes or myleodysplastic/myeloproliferative neoplasms. Applicable Procedure Code: J0896.

Reduced Services (CES) – Oxford Reimbursement Policy

Effective Date: 06.01.2020 – This policy addresses the use of modifier 52 (reduced services) for services or procedures that are partially reduced or eliminated at the discretion of the qualified health care professional.

Referrals

Effective Date: 04.01.2020 – This policy addresses referrals to a specialist, hospital, or ancillary provider.

Reimbursement for Comprehensive and Component CPT Codes (CES) – Oxford Reimbursement Policy

Effective Date: 03.01.2020 – This policy addresses the payment methodology utilized by Oxford in determining claims reimbursement when multiple procedures are performed in the same session by the same provider.

Replacement Codes – Oxford Reimbursement Policy

Effective Date: 01.11.2021 – This policy addresses specific codes assigned status code "I" on the National Physician Fee Schedule (NPFS) where the Centers for Medicare and Medicaid Services (CMS) has indicated a replacement code is available and has assigned a Relative Value Unit (RVU) to the replacement code. Applicable Procedure Codes: 44705, 77387, 77402, 77407, 77412, 95941, 97014, 99417, G0283, G0453, G0455, G2212, G6001, G6002, G6003, G6007, G6011.

Repository Corticotropin Injection (Acthar® Gel)

Requests for In-Network Exceptions – Oxford Administrative Policy

Effective Date: 09.01.2020 – This policy addresses the review of in-network exception requests for members residing within Oxford's service area.

Respiratory Interleukins (Cinqair®, Fasenra®, & Nucala®) – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of interleukin-5 (IL-5) antagonists, including Cinqair® (reslizumab), Fasenra® (benralizumab), and Nucala® (mepolizumab). Applicable Procedure Codes: J0517, J2182, J2786.

Review at Launch for New to Market Medications – Oxford Clinical Policy

Effective Date: 11.01.2020 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.

Rhinoplasty and Other Nasal Surgeries – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, septal dermatoplasty, and nasal polypectomy. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30560, 30620, 31237.

Rituximab ((Riabni™, Rituxan®, Ruxience®, & Truxima®) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Riabni™ (rituximab-arrx), Rituxan® (rituximab), Ruxience® (rituximab-pvvr), and Truxima® (rituximab-abbs). Applicable Procedure Codes: J9311, J9312, Q5115, Q5119.

Robotic Assisted Surgery Policy (CES) – Oxford Reimbursement Policy

Effective Date: 12.01.2020 – This policy addresses robotic-assisted surgery. Applicable Procedure Code: S2900.

Routine Foot Care – Oxford Clinical Policy

Effective Date: 05.01.2021 – 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.

Same Day/Same Service Policy (CES) – Oxford Reimbursement Policy

Effective Date: 11.01.2020 – This policy addresses multiple medical and/or evaluation and management (E/M) services for a patient on a single date of service.

Sandostatin LAR® Depot (Octreotide Acetate) – Oxford Clinical Policy

Effective Date: 12.01.2020 – This policy addresses the use of Sandostatin LAR® (octreotide acetate LAR). Applicable Procedure Code: J2353.

Scenesse® (Afamelanotide) – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses Scenesse® (afamelanotide) for the treatment of erythropoietic protoporphyria (EPP). Applicable Procedures Code: J7352.

Screening Colonoscopy Procedures – Site of Service – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses planned preventive screening colonoscopies performed in a hospital outpatient department. Applicable Procedures Codes: 45378, 45380, 45381, 45384, 45385, G0105, G0121.

Sensory Integration Therapy and Auditory Integration Training – Oxford Clinical Policy

Effective Date: 12.01.2020 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.

Services and Modifiers Not Reimbursable to Healthcare Professionals – Oxford Reimbursement Policy

Effective Date: 01.01.2021 – This policy addresses services and modifiers not reimbursable to healthcare professionals.

Services Requiring Prior Authorization – Oxford Administrative Policy

Effective Date: 05.01.2021 – This policy addresses services requiring prior authorization and their related policies.

Shoulder Replacement Surgery (Arthroplasty) – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses shoulder replacement surgery (arthroplasty and hemiarthroplasty). Applicable Procedure Codes: 23470, 23472, 23473, 23474.

Simponi Aria® (Golimumab) Injection for Intravenous Infusion – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses Simponi Aria® (golimumab) injection for intravenous infusion for the treatment of ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis. Applicable Procedure Code: J1602.

Site of Service Differential – Oxford Reimbursement Policy

Effective Date: 02.01.2021 – This policy addresses a site of service differential that reduces practice expense payments for services provided in facility or ambulance settings.

Skilled Care and Custodial Care Services – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses skilled care and custodial care services. Applicable Procedure Codes: 99509, S5100, S5101, S5102, S5105, S5120, S5121, S5125, S5126, S5130, S5131, S5135, S5136, S5140, S5141, S5150, S5151, S5170, S5175, S9125, T1005, T1019, T1020.

Skin and Soft Tissue Substitutes – Oxford Clinical Policy

Effective Date: 12.01.2020 – This policy addresses skin and soft tissue substitutes.

Sodium Hyaluronate – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses intra-articular injections of sodium hyaluronate. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.

Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting – Oxford Clinical Policy

Effective Date: 10.01.2020 – This policy addresses certain specialty medications provided in an outpatient hospital setting that must be obtained from the designated specialty pharmacy. Applicable Procedure Codes: J0129, J0202, J0717, J1602, J1745, J2323, J2350, J2507, J3262, J3357, J3358, J3380, Q5103, Q5104.

Speech Generating Devices – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses speech generating devices. Applicable Procedure Codes: E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599.

Speech Therapy and Early Intervention – Oxford Clinical Policy

Effective Date: 09.01.2020 – 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.

Spinraza® (Nusinersen) – Oxford Clinical Policy

Effective Date: 11.01.2020 – This policy addresses the use of Spinraza® (nusinersen) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J2326.

Split Surgical Package Policy (CES) – Oxford Reimbursement Policy

Effective Date: 08.01.2020 – This policy addresses split surgical package situations.

Spravato® (Esketamine) – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses the use of Spravato® (esketamine) for the treatment of treatment-resistant depression (TRD) and major depressive disorder (MDD). Applicable Procedure Codes: J3490, S0013.

Standby Services Policy – Oxford Reimbursement Policy

Effective Date: 06.01.2020 – This policy addresses standby services and hospital mandated on-call services. Applicable Procedure Codes: 99026, 99027, 99360.

Stelara® (Ustekinumab) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Stelara® (ustekinumab) for the treatment of Crohn’s disease, plaque psoriasis, psoriatic arthritis, and ulcerative colitis. Applicable Procedure Codes: J3357, J3358.

Supply Policy – Oxford Reimbursement Policy

Effective Date: 04.19.2021 – This policy addresses codes representing supplies, drugs, and other items based on the place of service (POS) submitted on the claim.

Surgery of the Hip – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses surgery of the hip and femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 29860, 29861, 29862, 29863, 29914, 29915, 29916, 29999, S2118.

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins – Oxford Clinical Policy

Effective Date: 05.01.2021 – 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.

Surgical Treatment for Spine Pain – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses surgical treatment for spine pain.

Synagis® (Palivizumab) – Oxford Clinical Policy

Effective Date: 10.01.2020 – This policy addresses the use of Synagis® (palivizumab) to prevent serious respiratory syncytial virus disease (RSV) in high risk infants and young children. Applicable Procedure Code: 90378.

T Status Codes Policy (CES) – Oxford Reimbursement Policy

Effective Date: 02.08.2021 – This policy addresses procedure codes assigned a "T" status indicator on the National Physician Fee Schedule (NPFS) by the Centers for Medicare and Medicaid Services (CMS). Applicable Procedure Codes: 36598, 94760, 94761, 96523, G0117, G0118.

Telehealth/Telemedicine Policy (CES) – Oxford Reimbursement Policy

Effective Date: 04.19.2021 – This policy addresses telemedicine and telehealth services.

Temporomandibular Joint Disorders – Oxford Clinical Policy

Effective Date: 05.01.2021 – 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.

Tepezza® (Teprotumumab-Trbw) – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Code: J3241.

Therapeutic Shoes and Inserts for Diabetes – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses therapeutic shoes and inserts for diabetics. Applicable Procedure Codes: A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, A5514.

Thermography – Oxford Clinical Policy

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.

Time Span Codes Policy – Oxford Reimbursement Policy

Effective Date: 04.19.2021 – This policy addresses time span codes.

Timeframe Standards for Benefit Administrative Initial Decisions

Effective Date: 01.01.2020 – This policy addresses initial benefit administrative decision and notification timeframes.

Timeframe Standards for Utilization Management (UM) Initial Decisions

Effective Date: 05.01.2020 – This policy addresses initial utilization management decision and notification timeframes.

Total Artifical Disc Replacement for the Spine – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899.

Total Artificial Heart and Ventricular Assist Devices – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the SynCardia™ temporary Total Artificial Heart. Applicable Procedure Codes: 33927, 33928, 33975, 33976, 33979, 33981, 33982, 33983, 33995, 33997.

Transcatheter Heart Valve Procedures – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33999, 93799.

Transcranial Magnetic Stimulation – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.

Transcutaneous Electrical Nerve/Joint Stimulators – Oxford Clinical Policy

Effective Date: 05.01.2021 – 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.

Transpupillary Thermotherapy – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.

Trogarzo™ (Ibalizumab-Uiyk) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Trogarzo® (ibalizumab-uiyk) for the treatment of multi-drug resistant human immunodeficiency virus (HIV). Applicable Procedure Code: J1746.

Tysabri® (Natalizumab) – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses the use of Tysabri® (natalizumab) for the treatment of relapsing forms of multiple sclerosis and Crohn's disease. Applicable Procedure Code: J2323.

Umbilical Cord Blood Harvesting and Storage for Future Use – Oxford Clinical Policy

Effective Date: 07.01.2020 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.

Unicondylar Spacer Devices for Treatment of Pain or Disability – Oxford Clinical Policy

Effective Date: 10.01.2020 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.

Uplizna® (Inebilizumab-Cdon) – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses Uplizna® (inebilizumab-cdon) for the treatment of neuromyelitis optica spectrum disorder (NMOSD). Applicable Procedures Code: J1823.

Urgent Care – Oxford Reimbursement Policy

Effective Date: 10.01.2020 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.

Vaccines – Oxford Clinical Policy

Effective Date: 09.01.2020 – This policy addresses vaccines/immunizations.

Vagus and External Trigeminal Nerve Stimulation – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 64553, 64568, 64570, E0770, E1399, K1016, K1017, K1020, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.

Vertebral Body Tethering for Scoliosis – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Code: 22899.

Viltepso® (Viltolarsen) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses Viltepso® (viltolarsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Codes: J1427.

Virtual Upper Gastrointestinal Endoscopy – Oxford Clinical Policy

Effective Date: 12.01.2020 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.

Vision Services (Including Refractive Surgery) – Oxford Administrative Policy

Effective Date: 01.01.2021 – This policy addresses the benefit and coverage considerations for vision services.

Visual Information Processing Evaluation and Orthoptic and Vision Therapy – Oxford Clinical Policy

Effective Date: 05.01.2021 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 92065, 92499.

Vyepti™ (Eptinezumab-Jjmr) – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses the use of Vyepti™ (Eptinezumab) for the treatment of chronic and episodic migraine. Applicable Procedure Code: J3032.

Vyondys 53™ (Golodirsen) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Vyondys 53™ (golodirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1429.

Warming Therapy and Ultrasound Therapy for Wounds – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 97610, A6000, E0231, E0232.

Wheelchair Options and Accessories

Effective Date: 05.01.2021 – This policy addresses wheelchair options and accessories.

Wheelchair Seating – Oxford Clinical Policy

Effective Date: 05.01.2021 – 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.

White Blood Cell Colony Stimulating Factors – Oxford Clinical Policy

Effective Date: 01.01.2021 – This policy addresses the use of white blood cell colony stimulating factors (CSFs), including the drug products Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nyvepria, Udenyca, Zarxio, and Ziextenzo. Applicable Procedure Codes: J1442, J1447, J2505, J2820, JQ5101, Q5108, Q5110, Q5111, Q5120, Q5122.

Whole Exome and Whole Genome Sequencing

Wrong Surgical or Other Invasive Procedures Policy – Oxford Reimbursement Policy

Effective Date: 11.01.2020 – This policy addresses wrong surgical or other invasive procedures performed on a patient.

Xiaflex® (Collagenase Clostridium Histolyticum) – Oxford Clinical Policy

Effective Date: 04.01.2021 – This policy addresses the use of Xiaflex® (collagenase clostridium histolyticum) for the treatment of Dupuytren’s contracture and Peyronie’s disease. Applicable Procedure Codes: 20527, 26341, J0775.

Xolair® (Omalizumab) – Oxford Clinical Policy

Effective Date: 03.01.2021 – This policy addresses the use of Xolair® (omalizumab) for subcutaneous use for the treatment of moderate to severe persistent asthma, chronic urticaria, and nasal polyps. Applicable Procedure Code: J2357.

Zolgensma® (Onasemnogene Abeparvovec-Xioi) – Oxford Clinical Policy

Effective Date: 02.01.2021 – This policy addresses the use of Zolgensma® (onasemnogene abeparvovec-xioi) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J3399.

Zulresso™ (Brexanolone) – Oxford Clinical Policy

Effective Date: 10.01.2020 – This policy addresses the use of Zulresso™ (brexanolone) for the treatment of postpartum depression (PPD) in adults. Applicable Procedure Code: J1632.