The Clinical Policies, Administrative Policies, Reimbursement Policies and corresponding update bulletins for UnitedHealthcare Oxford plans are listed below.
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A monthly notice of recently approved and/or revised Clinical Policies, Administrative Policies and Reimbursement Policies is provided below for your review. We publish a new announcement on the first calendar day of every month.
The appearance of a health service (e.g., test, drug, device or procedure) in the Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
01/01/2020 - Oxford Policy Update Bulletin: January 2020
Last Modified 01.01.2020
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
11/01/2019 - Oxford Policy Update Bulletin: November 2019
Last Modified 01.01.2020
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
12/01/2019 - Oxford Policy Update Bulletin: Month 2019
Last Modified 01.01.2020
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
Oxford Policy Update Bulletin Archive
Last Modified 01.01.2020
Current Policies
UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies
Please read the terms and conditions below carefully.
A complete library of the UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies is available here for your reference. The appearance of an item or procedure on the list indicates only that we have adopted a policy; it does not imply that we provide coverage for the item or procedure listed.
The services described in our policies are subject to the terms, conditions and limitations of the member's contract or certificate. We reserve the right, in our sole discretion, to modify policies as necessary without prior written notice unless otherwise required by our administrative procedures or applicable state law. The terms "our" and "we" include Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.
Certain policies may not be applicable to self-funded members and certain insured products. Refer to the member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member's plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.
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17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 08.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 64625, 64633, 64634, 64635, 64636, 64999.
Abnormal Uterine Bleeding and Uterine Fibroids – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 09.01.2019 – 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 Administrative Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – 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 – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 04.01.2019 – This policy addresses accreditation requirements for radiologists, radiology centers and multi-speciality provider groups interested in participating in the Oxford network.
Acquired Rare Disease Drug Therapy Exception Process – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 02.01.2019 – This policy addresses the exception process for the experimental/investigational treatment (drug therpay) of an acquired rare disease.
Actemra® (Tocilizumab) Injection for Intravenous Infusion – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 05.01.2019 – This policy addresses the use of Actemra® (tocilizumab) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, systemic juvenile idiopathic arthritis, and cytokine release syndrome. Applicable Procedure Code: J3262.
Acupuncture – Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses acupuncture services. Applicable Procedure Codes: 97014, 97032, 97810, 97811, 97813, 97814, A4212, A4215, G0283, S8930.
Add-On Policy – Oxford Reimbursement Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses physicians reporting evaluation and management (E/M) services on behalf of their employed advanced practice healthcare providers denoting the services were provided in collaboration with a physician.
After Hours and Weekend Care – Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 05.01.2019 – This policy addresses procedure codes for after hours and weekend care services. Applicable Procedure Codes: 99050, 99051, 99053, 99056, 99058, 99060.
Alpha1-Proteinase Inhibitors – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®-C, and Zemaira®) for chronic augmentation and maintenance therapy of emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI)/alpha1-antitrypsin (AAT) deficiency. Applicable Procedure Codes: J0256, J0257.
Ambulance Services – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services. Applicable Procedure Codes: A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0998, A0999, S0207, S0208, S9960, S9961, T2007.
Ambulance – Oxford Reimbursement Policy
Last Modified 01.21.2020
Effective Date: 01.21.2020 – 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.
Anesthesia (CES) – Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Articular Cartilage Defect Repairs - Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses autologous chondrocyte transplantation (ACT), osteochondral autograft and allograft transplantation, microfracture repair of the knee, and focal articular cartilage repair. Applicable Procedure Codes: 27412, 27415, 27416, 28446, 29866, 29867, 29879, J7330, S2112.
Assignment of Benefits & Balance Billing – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date 07.01.2018 – This policy addresses assignment of benefits for services rendered by non-network providers and balance billing.
Assistant-at-Surgery – Oxford Reimbursement Policy
Last Modified 01.21.2020
Effective Date: 01.21.2020 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses assisted administration of clotting factors and coagulant blood products, including home health care services. Applicable Procedure Codes: 99601, 99602, 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, J7205, J7207, J7208, J7209, J7210, J7211, S9345.
Athletic Pubalgia Surgery – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.
Attended Polysomnography for Evaluation of Sleep Disorders – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 04.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses services for the treatment of autism.
B Bundle Codes (CES) – Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298.
Bariatric Surgery – Oxford Clinical Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, gastric sleeve procedure, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.
Behavioral Health Services – Oxford Administrative Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses behavioral health services for the treatment of mental health and substance use disorders.
Benlysta® (Belimumab) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 05.01.2019 – This policy addresses the use of Benlysta® (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE). Applicable Procedure Code: J0490.
Bilateral Procedures (CES) – Oxford Reimbursement Policy
Last Modified 01.21.2020
Effective Date: 01.21.2020 – 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 health care professional, including procedure codes with "bilateral" in the description.
Blepharoplasty, Blepharoptosis and Brow Ptosis Repair – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 07.01.2019 – This policy addresses upper and lower eyelid blepharoplasty, upper eyelid blepharoptosis repair, brow ptosis, brow ptosis repair, eyelid surgery with an anophthalmic socket, ectropion or punctal eversion, entropion, lid retraction surgery, canthoplasty/canthopexy, and repair of floppy eyelid syndrome (FES). Applicable Procedure Codes: 15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.
Bone or Soft Tissue Healing and Fusion Enhancement Products – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Applicable Procedure Codes: J0585, J0586, J0587, J0588.
Breast Imaging for Screening and Diagnosing Cancer – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses breast imaging, including digital mammography, magnetic resonance imaging (MRI), ultrasound, automated breast ultrasound system, computer-aided detection (CAD), computer-aided tactile breast imaging, electrical impedance scanning (EIS), magnetic resonance elastography (MRE), and scintimammography. Applicable Procedure Codes: 0422T, 76376, 76377, 76391, 76498, 76499, 76641, 76642, 77046, 77047, 77048, 77049, 77065, 77066, 77067, S8080.
Breast Reconstruction Post Mastectomy – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses breast reconstruction post-mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19301, 19302, 19303, 19305, 19306, 19307, 19316, 19318, 19324, 19325, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Breast Reduction Surgery - Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Breast Repair/Reconstruction Not Following Mastectomy – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.
Brineura™ (Cerliponase Alfa) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 08.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 07.01.2019 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.
Buprenorphine (Probuphine® & Sublocade™) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0295T, 0296T, 0297T, 0298T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272, 93285, 93291, 93298, E0616, G2066.
Cardiology Procedures Requiring Precertification for eviCore healthcare Arrangement - Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses cardiology procedures requiring precertification with initial review performed by eviCore healthcare.
Cardiovascular Disease Risk Tests – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 01.01.2019 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme and other human A2 phospholipases, long-chain omega-3 fatty acids, and endothelial function assessment. Applicable Procedure Codes: 0052U, 0111T, 0126T, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.
Care Plan Oversight – Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 11.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 07.01.2019 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 81412, 81443, 81479.
Chelation Therapy for Non-Overload Conditions – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 03.01.2019 – This policy addresses chelation therapy. Applicable Procedure Codes: J3490, M0300, S9355.
Chemosensitivity and Chemoresistance Assays in Cancer – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses chemosensitivity and chemoresistance assays in cancer. Applicable Procedure Codes: 0083U, 0564T, 81535, 81536, 86849, 89240.
Chromosome Microarray Testing (Non-Oncology Conditions) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 07.01.2019 – This policy addresses genome-wide comparative genomic hybridization microarray testing or single nucleotide polymorphism (SNP) chromosomal microarray analysis. Applicable Procedure Codes: 81228, 81229, 81479, S3870.
Cimzia® (Certolizumab Pegol) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses the use of Cimzia® (certolizumab pegol) for the treatment of Crohn’s disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, and plaque psoriasis. Applicable Procedure Codes: 96372, 96401, J0717.
Claims Recovery – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 02.01.2019 – This policy addresses recovery of claim overpayments.
Clinical Review – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 01.01.2019 – This policy addresses the review of clinical information for the purposes of determining eligibility of coverage, precertification of medical services, and claim payment.
Clinical Trials – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 07.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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, J7205, J7207, J7208, J7209, J7210, J7211.
Co-Surgeon/Team Surgeon (CES) - Oxford Reimbursement Policy
Last Modified 01.21.2020
Effective Date: 01.21.2020 – This policy addresses co-surgeon and team surgeon services.
Cochlear Implants – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 04.01.2019 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Collagen Crosslinks and Biochemical Markers of Bone Turnover – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 02.01.2019 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Complement Inhibitors (Soliris® & Ultomiris™) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses the use of Soliris® (eculizumab) for the treatment of atypical hemolytic uremic syndrome (aHUS), paroxysmal nocturnal hemoglobinuria (PNH), generalized myasthenia gravis, and neuromyelitis optica spectrum disorder (NMOSD), and the use of Ultomiris™ (ravulizumab-cwvz) for the treatment of paroxysmal nocturnal hemoglobinuria (PNH). Applicable Procedure Codes: J1300, J1303.
Computer-Assisted Surgical Navigation for Musculoskeletal Procedures – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses computer-assisted surgical navigation for musculoskeletal procedures and the use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty. Applicable Procedure Codes: 0054T, 0055T, 0396T, 20985.
Computerized Dynamic Posturography – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.
Consultation Services – Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4226, A9274, A9276, A9277, A9278, E0784, E0787, E1399, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.
Contraceptives – Oxford Administrative Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses contraceptive procedures/appliances/devices and injectable drugs provided in a physician’s office.
Coordination of Benefits – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 02.01.2019 – This policy addresses the 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
Last Modified 11.22.2019
Effective Date: 09.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses measurement of corneal hysteresis, measurement of ocular blood flow, and monitoring of intraocular pressure. Applicable Procedure Codes: 0198T, 0329T, 66999, 67299, 92145.
Cosmetic and Reconstructive Procedures – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses cosmetic and reconstructive procedures.
Credentialing Guidelines: Participation in the eviCore healthcare Network – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date 10.01.2017 – This policy addresses credentialing guidelines for radiologists and cardiologists interested in participating in the eviCore healthcare network.
Crysvita® (Burosumab-Twza) – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses the use of Crysvita® (burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH). Applicable Procedure Code: J0584.
Cytological Examination of Breast Fluids for Cancer Screening – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 07.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses deep brain and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Denosumab (Prolia® & Xgeva®) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 05.01.2019 – This policy addresses the use of denosumab (Prolia® & Xgeva®). Applicable Procedure Code: J0897.
Dental and Oral Surgical Procedures – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 04.01.2019 – This policy addresses oral surgical and dental procedures and related anesthesia when determined to be medical in nature.
Diabetes Supply Coverage - Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 04.01.2019 – 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
Last Modified 11.22.2019
Effective Date 09.01.2018 – This policy addresses certain information disclosed to members and claimants regarding their claims in connection with an adverse determination or appeal of that determination.
Discogenic Pain Treatment – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses thermal intradiscal procedures (TIPs), 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
Last Modified 11.22.2019
Effective Date: 08.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses medications for which certain types of prescription drug benefit exclusions may apply.
Drug Coverage Guidelines – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses multiple drug coverage guidelines.
Drug Testing – Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses the daily limit for presumptive and definitive drug testing, and specimen validity testing. Applicable Procedure Codes: 0006U, 0007U, 0011U, 0082U, 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U, 80305, 80306, 80307, 81000, 81001, 81002, 81003, 81005, 82542, 82570, 83516, 83518, 83519, 83520, 83789, 83986, 84156, 84311, G0480, G0481, G0482, G0483, G0659, H0003.
Durable Medical Equipment, Orthotics and Prosthetics (CES) – Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses rental and/or purchase of certain items of durable medical equipment (DME), prosthetics, and orthotics.
Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements – Oxford Administrative Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.
Elbow Replacement Surgery (Arthroplasty) – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.
Electric Tumor Treatment Field Therapy – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 11.01.2019 – 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
Last Modified 12.04.2019
Effective Date: 08.01.2019 – This policy addresses electrical, electromagnetic, and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20975, 20979, E0747, E0748, E0749, E0760.
Electrical Bioimpedance for Cardiac Output Measurement – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 09.01.2019 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.
Electrical Stimulation and Electromagnetic Therapy for Wounds – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 02.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Applicable Procedure Codes: 0278T, 63650, 63655, 63685, 64999, E0744, E0745, E0762, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Electroencephalographic (EEG) Monitoring and Video Recording – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.
Eloctate™ (Antihemophilic Factor (Recombinant), FC Fusion Protein) for Connecticut Lines of Business – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 11.22.2019
Effective Date: 04.01.2019 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Emergency Room Visits (Including Coverage for Members Outside of the United States) – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses emergency room visits, including services provided outside of the United States.
Entyvio® (Vedolizumab) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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 and Facet Injections for Spinal Pain – Oxford Clinical Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses epidural steroid and facet injections for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0230T, 0231T, 62322, 62323, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495.
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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, 64999, 72295.
Erythropoiesis-Stimulating Agents - Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses evaluation and management (E/M) services, including E/M services rendered in an emergency department (ER/ED) place of service.
Evenity™ (Romosozumab-Aqqg) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses the use of Evenity™ (romosozumab- aqqg) for the treatment of osteoporosis in postmenopausal patients at high risk for fracture. Applicable Procedure Code: J3111.
Exondys 51® (Eteplirsen) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 04.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 02.01.2019 – This policy addresses experimental and/or investigational treatment or procedures for New Jersey (NJ) Plans.
Experimental/Investigational Treatment – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 02.01.2019 – This policy addresses experimental and/or investigational treatment or procedures.
Extended Benefits for Total Disability & Succeeding Carrier for Inpatient Admissions – Oxford Administrative Policy
Last Modified 12.01.2019
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) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses extracorporeal shock wave therapy (ESWT). Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.
Fecal Calprotectin Testing – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.
Femoroacetabular Impingement Syndrome Treatment – Oxford Clinical Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses surgical treatment for femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27299, 29914, 29915, 29916, 29999.
Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses DNA-based noninvasive prenatal tests of fetal aneuploidy. Applicable Procedure Codes: 0060U, 81420, 81422, 81479, 81507.
Filing Deadlines for Claims Submissions – Oxford Administrative Policy
Last Modified 12.01.2019
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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses follow-up care when rendered in an emergency room (ER) site of service/setting.
Formula & Specialized Food – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 03.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses the "from" and "to" dates reported on claims.
Functional Endoscopic Sinus Surgery (FESS) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Gait Analysis – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 06.01.2017 – This policy addresses gait analysis. Applicable Procedure Codes: 96000, 96001, 96002, 96003, 96004.
Gamifant™ (Emapalumab-Lzsg) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses the use of Gamifant™ (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.
Gastrointestinal Motility Disorders, Diagnosis and Treatment – Oxford Clinical Policy
Last Modified 12.01.2019
Effective Date: 05.01.2019 – This policy addresses gastric electrical stimulation therapy, manometry and rectal sensation, tone, and compliance test, conventional defecography, electrogastrography, and electroenterography. Applicable Procedure Codes: 43647, 43648, 43881, 43882, 64590, 64595, 76496, 76498, 91117, 91120, 91122, 91132, 91133.
Gender Dysphoria Treatment – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses gender dysphoria treatment, including gender reassignment surgery and certain ancillary procedures.
Genetic Testing for Cardiac Disease – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 81410, 81411, 81413, 81414, 81439, 81443, 81493.
Genetic Testing for Hereditary Cancer – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 81443, 81440, 81460, 81465, 81479.
Glaucoma Surgical Treatments – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 08.01.2019 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and viscocanalostomy. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 66170, 66174, 66175, 66179, 66180, 66183, 66184, L8612.
Global Days – Oxford Reimbursement Policy
Last Modified 01.21.2020
Effective Date: 01.21.2020 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products, including Firmagon (degarelix), Lupaneta Pack (leuprolide acetate injection and norethindrone acetate tablets), Lupron Depot (leuprolide acetate), Lupron Depot-Ped (leuprolide acetate), Supprelin LA (histrelin acetate), Trelstar (triptorelin pamoate), Triptodur (triptorelin), Vantas (histrelin acetate), and Zoladex (goserelin acetate). Applicable Procedure Codes: J1950, J3315, J3316, J9155, J9202, J9217, J9225, J9226.
Gynecomastia Treatment – Oxford Clinical Policy
Last Modified 07.15.2019
Effective Date: 07.01.2019 – This policy addresses mastectomy or suction lipectomy. Applicable Procedure Code: 19300.
Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable – Oxford Clinical Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.
High Frequency Chest Wall Compression Devices – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses high-frequency chest wall compression (HFCWC). Applicable Procedure Codes: A7025, A7026, E0483.
Hip Resurfacing and Replacement Surgery (Arthroplasty) – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.
Home Health Care – Oxford Clinical Policy
Last Modified 08.01.2019
Effective Date: 08.01.2019 – This policy addresses home health care services.
Home Hemodialysis – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 03.01.2019 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Home Traction Therapy – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 05.01.2019 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Hospice Care – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 12.01.2017 – This policy addresses hospice care services. Applicable Procedure Codes: 99377, 99378, G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0182, G0299, G0300, G0337, G9473, G9474, G9475, G9476, G9477, G9478, G9479, Q5001, Q5002, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5009, Q5010, S0255, S0271, S9126, T2042, T2043, T2044, T2045, T2046.
Human Menopausal Gonadotropins (hMG) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 08.01.2019 – This policy addresses human menopausal gonadotropins (hMG), including Menopur® (menotropins for injection). Applicable Procedure Codes: S0122, S4042.
Hysterectomy for Benign Conditions – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58541, 58542, 58543, 58544, 58570, 58571, 58572, 58573, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58550, 58552, 58553, 58554.
Ilaris® (Canakinumab) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – 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), and systemic juvenile idiopathic arthritis (SJIA). Applicable Procedure Code: J0638.
Ilumya™ (Tildrakizumab-Asmn) - Oxford Clinical Policy
Last Modified 09.01.2019
Effective Date: 09.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products, including Asceniv™, Bivigam™, Carimune® NF, Cutaquig®, Cuvitru™, Flebogamma® DIF, Gammagard® Liquid, Gammagard® S/D, Gammaked™, Gammaplex®, Gamunex®-C, Hizentra®, HyQvia®, Octagam®, Panzyga®, Privigen®, and Xembify®. Applicable Procedure Codes: 90283, 90284, J1459, J1555, J1556, J1557, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599.
Immune Globulin - Site of Care - Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 05.01.2019 – This policy addresses hospital outpatient facility infusion services for intravenous and subcutaneous immune globulin (IVIG and SCIG) therapy.
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 01.01.2019 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of unresectable metastatic liver tumors from primary colorectal cancer (CRC), unresectable metastatic liver tumors from neuroendocrine tumors, unresectable primary hepatocellular carcinoma (HCC), and unresectable intrahepatic cholangiocarcinoma. Applicable Procedure Codes: 37243, 79445, S2095.
Implanted Electrical Stimulator for Spinal Cord – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses implanted electrical stimulators 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
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses in-network exceptions for breast reconstruction surgery after mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19316, 19324, 19325, 19330, 19340, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380, 19396, 19499, 19318, L8600, S2066, S2067, S2068, S8950.
In-Office Laboratory Testing and Procedures List – Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 05.01.2019
Effective Date: 05.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses diagnostic and therapeutic procedures for infertility and cryopreservation.
Infliximab (Remicade®, Inflectra™, Renflexis™) – Oxford Clinical Policy
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses the use of infliximab products as tumor necrosis factor (TNF) blockers, including Remicade® (infliximab), Inflectra™ (infliximab-dyyb), and Renflexis™ (infliximab-abda). Applicable Procedure Codes: J1745, Q5103, Q5104, Q5109.
Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 08.01.2019
Effective Date: 05.01.2019 – This policy addresses therapeutic and diagnostic injection and infusion services, including related supplies and/or drugs. Applicable Procedure Codes: 96360, 96361, 96365, 96366, 96367, 96368, 96369, 96370, 96371, 96372, 96373, 96374, 96375, 96376, 96377, 96379, 96401, 96402, 96405, 96406, 96409, 96411, 96413, 96415, 96416, 96417, 96420, 96422, 96423, 96425, 96440, 96446, 96450, 96521, 96522, 96523, 96542, 96549, G0498.
Inpatient Maternity Stay and Subsequent Home Nursing – Oxford Administrative Policy
Last Modified 12.01.2019
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) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.
Intraoperative Neuromonitoring - Oxford Clinical Policy
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses intraoperative neuromonitoring (IONM) services. Applicable Procedure Codes: 95940, 95941, G0453.
Intrauterine Fetal Surgery – Oxford Clinical Policy
Last Modified 05.01.2019
Effective Date: 05.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 10.01.2019 – 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.
Knee Replacement Surgery (Arthroplasty), Total and Partial – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.
Krystexxa® (Pegloticase) – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 11.22.2019
Effective Date: 08.01.2019 – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 64999.
Lemtrada (Alemtuzumab) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 08.01.2019 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 17106, 17107, 17108, 17380.
Lithotripsy for Salivary Stones – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.
Lower Extremity Vascular Angiography – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 10.01.2019 – This policy addresses lower extremity vascular angiography for evaluating arterial disease of the lower extremity. Applicable Procedure Codes: 75710, 75716.
Luxturna™ (Voretigene Neparvovec-Rzyl) – Oxford Clinical Policy
Last Modified 12.23.2019
Effective Date: 11.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses the use of parenteral antibiotics for treating Lyme disease. Applicable Procedure Codes: J0696, J0698, J2510, J2540, J0558, J0561.
Macular Degeneration Treatment Procedures – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 05.01.2019 – This policy addresses macular degeneration treatment procedures, including Implantable Miniature Telescope (IMT), conjunctival incision with posterior extrascleral placement of a pharmacologic agent, epiretinal radiation therapy, and laser photocoagulation. Applicable Procedure Codes: 0308T, 67036, 67299, 92499.
Manipulation Under Anesthesia – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 02.01.2019 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 24300, 25259, 26340, 27198, 27275, 27570, 27860, D7830.
Manipulative Therapy – Oxford Clinical Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.
Maximum Dosage – Oxford Clinical Policy
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses the maximum dosage per administration for medications administered by a medical professional. Applicable Procedure Codes: J0222, J0717, J0897, J1300, J1303, J1745, J2357, J2505, J3357, J3358, J3380, J3489, J9035, J9299, J9312, J9355, Q5103, Q5104, Q5107, Q5108, Q5111, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118.
Maximum Frequency Per Day (CES) – Oxford Reimbursement Policy
Last Modified 12.16.2019
Effective Date: 11.04.2019 – This policy addresses maximum frequency per day determinations for services/procedures.
Mechanical Circulatory Support Device (MCSD) – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 02.01.2019 – This policy addresses the use of long term, durable mechanical circulatory support devices. Applicable Procedure Codes: 33975, 33976, 33979, 33981, 33982, 33983.
Mechanical Stretching Devices – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841.
Member Administrative Grievance & Appeal (Non UM) Process & Timeframes – Oxford Administrative Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses the process and timeframes of an administrative grievance/appeal.
Meniscus Implant and Allograft – Oxford Clinical Policy
Last Modified 09.23.2019
Effective Date: 06.01.2019 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.
Microsurgery (CES) - Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses use of an operating microscope during a surgical procedure. Applicable Procedure Codes: 64727, 69990.
Mifeprex® (Mifepristone) – Oxford Clinical Policy
Last Modified 05.01.2019
Effective Date: 05.01.2019 – 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) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses minimally invasive procedures for treating gastroesophageal reflux disease (GERD). Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43499, 43999.
Modifier Reference (CES) - Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 03.01.2019 – This policy addresses other reimbursement policies in which modifiers are addressed.
Modifier SU – Oxford Reimbursement Policy
Last Modified 12.01.2019
Effective Date: 05.01.2019 – This policy addresses reimbursement for claims appended with modifier SU.
Mohs Micrographic Surgery – Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 01.15.2020
Effective Date: 01.01.2020 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.
Motorized Spinal Traction – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 05.01.2019 – 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
Last Modified 01.07.2020
Effective Date: 01.01.2020 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 12.01.2019
Effective Date: 06.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 09.01.2019 – This policy addresses sural or other nerve grafts to restore erectile function during radical prostatectomy. Applicable Procedure Codes: 55899, 64999.
Neurophysiologic Testing and Monitoring – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 09.01.2019 – This policy addresses nerve conduction studies and other neurophysiological testing.
Neuropsychological Testing Under the Medical Benefit – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses neuropsychological testing and computerized cognitive testing under the medical benefit. Applicable Procedure Codes: 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146.
New Patient Visit – Oxford Reimbursement Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses new patient visits. Applicable Procedure Codes: 92002, 92004, 99201, 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.
New York & Connecticut Participating Surgeons Using Non-Participating Providers for Intraoperative Neuro-Monitoring (IONM) - Oxford Administrative Policy
Last Modified 07.09.2019
Effective Date: 06.01.2018 – This policy addresses procedures and responsibilities for New York and Connecticut participating providers using non-participating providers for intraoperative neuro-monitoring (IONM) in an outpatient or inpatient facility setting.
New York Providers Protocols and Guidelines – Oxford Administrative Policy
Last Modified 12.01.2019
Effective date 06.01.2016 – This policy addresses protocols and guidelines for health care professionals in the state of New York.
Newborns – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 04.01.2018 – This policy addresses enrollment and coverage of newborns.
Non-Participating Provider Consent Form Protocol – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 03.01.2018 – This policy addresses the use of a non-participating provider in a member’s care and the Member Advanced Notice Form.
Nonphysician Health Care Codes – Oxford Reimbursement Policy
Last Modified 01.21.2020
Effective Date: 01.21.2020 – 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, G2061, G2062, G2063.
Nonphysician Health Care Professionals Billing Evaluation and Management Codes - Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 02.01.2019 – This policy addresses evaluation and management (E/M) services reported by nonphysician health care professionals.
Observation and Discharge – Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses observation care services. Applicable Procedure Codes: 99217, 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, 99236, 99238, 99239.
Observation Care – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses observation care.
Obstetrical Policy – Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses global obstetrical (OB) codes and itemization of maternity care services. Applicable Procedure Codes: 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622.
Obstetrical Ultrasonography – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 12.04.2019
Effective Date: 08.01.2019 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0466T, 0467T, 0468T, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, E0485, E0486, L8679, L8680, L8686, S2080.
Occipital Neuralgia and Headache Treatment – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses occipital neuralgia and headache treatments, including injection of local anesthetics and/or steroids used as occipital nerve blocks, neurostimulation or electrical stimulation, occipital neurectomy, radiofrequency ablation (thermal or pulsed) or denervation, rhizotomy, and surgical nerve decompression. Applicable Procedure Codes: 62281, 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64633, 64634, 64722, 64744, 64771, 64999, L8679, L8680, L8685.
Ocrevus™ (Ocrelizumab), Ocrevus™ (Ocrelizumab) – Oxford Clinical Policy
Last Modified 08.01.2019
Effective Date: 08.01.2019 – 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
Last Modified 12.04.2019
Effective Date: 07.01.2019 – This policy addresses certain elective procedures which should be performed in an Office setting. Applicable Procedure Codes: 10120, 10140, 11400, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11442, 11606, 19000, 27096, 31579, 36473, 36475, 36478, 45300, 45330, 46922, 55250, 57460, 62270, 62320, 62321, 62322, 62323, 64479, 64483, 64490, 64493, 64520, 64633, 64635.
Office Based Procedures - Site of Service – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses multiple services/procedures.
Once in a Lifetime Procedures – Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 05.01.2019 – This policy addresses certain procedures reimbursed only once during a patient’s lifetime.
One or More Sessions (CES) – Oxford Reimbursement Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – 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
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses the use of Onpattro™ (patisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedure Code: J0222.
Orencia® (Abatacept) Injection for Intravenous Infusion – Oxford Clinical Policy
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses the use of Orencia® (abatacept) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, and psoriatic arthritis. Applicable Procedure Code: J0129.
Orthognathic (Jaw) Surgery – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 07.01.2019 – This policy addresses orthognathic (jaw) surgery.
Orthopedic Services – Oxford Administrative Policy
Last Modified 12.04.2019
Effective Date: 10.01.2019 – This policy addresses services subject to utilization review with OrthoNet’s orthopedic division.
Otoacoustic Emissions Testing – Oxford Clinical Policy
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses neonatal hearing screening, auditory screening, and diagnostic testing using otoacoustic emissions (OAEs). Applicable Procedure Codes: 92558, 92587, 92588.
Outpatient Physical & Occupational Therapy for Self-Funded Groups – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 03.01.2018 – This policy addresses outpatient physical and occupational therapy for self-funded groups. Applicable Procedure Codes: 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97760, 97761, 97799, G0151, G0152, G0283, S8990, S9129, S9131.
Outpatient Physical and Occupational Therapy (OptumHealth Care Solutions Arrangement) - Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 07.01.2018 – This policy addresses outpatient physical and occupational therapy for OptumHealth Care Solutions arrangements. Applicable Procedure Codes: 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97760, 97761, 97799, G0151, G0152, G0283, S8990, S9129, S9131.
Outpatient Surgical Procedures - Site of Service – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses sites of service for certain outpatient surgical procedures.
Oxford's Outpatient Imaging Self-Referral – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses self-referral for outpatient imaging services.
Panniculectomy and Body Contouring Procedures – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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.
Par Gastroenterologists Using Non-Par Anesthesiologists: In-Office & Ambulatory Surgery Centers – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 05.01.2019 – 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).
Par Surgeons Using Non-Par Assistant Surgeons and Co-Surgeons - Oxford Administrative Policy
Last Modified 04.01.2019
Effective Date: 01.01.2019 – This policy addresses participating surgeons located in New York using non-participating assistant surgeons and co-surgeons for non-emergent procedures.
Parsabiv™ (Etelcalcetide) - Oxford Clinical Policy
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses the use of Parsabiv™ (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.
Participating Provider Laboratory and Pathology Protocol – Oxford Administrative Policy
Last Modified 01.01.2020
Effective Date: 08.01.2019 – This policy addresses the applicable procedures and responsibilities for participating providers treating a member on a Connecticut (CT) or New York (NY) product and the provider 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.
Pectus Deformity Repair – Oxford Clinical Policy
Last Modified 07.15.2019
Effective Date: 07.01.2019 – 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
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses pediatric and neonatal critical and intensive care services. Applicable Procedure Codes: 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, 99480.
Percutaneous Vertebroplasty and Kyphoplasty – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 09.01.2019 – This policy addresses percutaneous vertebroplasty and kyphoplasty for treating spinal pain. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515.
Pharmacogenetic Testing – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses the use of pharmacogenetic multi-gene panel testing for genetic polymorphisms. Applicable Procedure Codes: 0029U, 0078U, 81479.
Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction - Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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, Occupational (OptumHealth Care Solutions Arrangement) and Speech Therapy Including Cognitive/ Neuropsychological Rehabilitation for New Jersey Small Group Members - Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 08.01.2018 – This policy addresses physical, occupational, speech, and cognitive therapy and therapeutic manipulation for New Jersey Small Group members. Applicable Procedure Codes: 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97760, 97761, 97799, G0151, G0152, G0283, S9129, S9131, S9152.
Physician Extenders – Oxford Reimbursement Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses physician extender eligibility for reimbursement of surgical and non-surgical services.
Plagiocephaly and Craniosynostosis Treatment – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses the use of cranial orthotic devices for treating infants with plagiocephaly and craniosynostosis. Applicable Procedure Codes: 21175, D5924, L0112, L0113, S1040.
Pneumatic Compression Devices – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Practitioner/Provider Administrative Claim Reconsideration and Appeal Process – Oxford Administrative Policy
Last Modified 04.01.2019
Effective Date: 01.01.2019 – This policy addresses the process and timeframes for participating practitioner and provider administrative claims appeals brought on their own behalf.
Precertification Exemptions for Outpatient Services – Oxford Administrative Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses services which are exempt from the standard outpatient precertification requirement.
Preimplantation Genetic Testing - Oxford Clinical Policy
Last Modified 11.01.2019
Effective Date: 06.01.2019 – This policy addresses preimplantation genetic testing (PGT). Applicable Procedure Codes: 81228, 81229, 81479.
Preterm Labor Management – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 12.01.2018 – This policy addresses tocolytic therapy, subcutaneous terbutaline pump maintenance therapy, magnesium sulfate, and home uterine activity monitoring (HUAM). Applicable Procedure Codes: J3105, J3475, S9001, S9349.
Preventive Care Services – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses preventive care services.
Preventive Medicine and Screening (CES) - Oxford Reimbursement Policy
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses preventive medicine and screening services.
Private Duty Nursing (PDN) Services – Oxford Clinical Policy
Last Modified 08.01.2019
Effective Date: 08.01.2019 – This policy addresses private duty nursing (PDN) services. Applicable Procedure Code: T1000.
Procedure and Place of Service – Oxford Reimbursement Policy
Last Modified 01.21.2020
Effective Date: 01.21.2020 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses the appropriate use of modifiers with individual CPT and HCPCS procedure codes.
Professional/Technical Component (CES) – Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 01.21.2020
Effective Date: 01.21.2020 – 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, G0513, G0514.
Prolotherapy and Platelet Rich Plasma Therapies – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 07.01.2019
Effective Date: 07.01.2019 – This policy addresses outpatient hospital facility-based intravenous medication infusion, including Actemra®, Aldurazyme®, Aralast NP™, Benlysta®, Cerezyme®, Crysvita®, Elaprase®, Elelyso®, Entyvio®, Exondys 51™, Fabrazyme®, Glassia™, Ilaris®, Ilumya™, Inflectra™, Kanuma®, Lumizyme®, Mepsevii™, Naglazyme®, Ocrevus™, Onpattro™, Orencia®, Prolastin®-C, Radicava™, Remicade®, Renflexis™, Revcovi™, Simponi Aria®, Soliris®, Trogarzo™, Ultomiris™, Vimizim®, VPRIV®, and Zemaira®.
Radiation Therapy Procedures Requiring Precertification for eviCore healthcare Arrangement - Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 03.01.2019 – This policy addresses radiation therapy services which require precertification by eviCore healthcare.
Radicava™ (Edaravone) – Oxford Clinical Policy
Last Modified 08.01.2019
Effective Date: 05.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses radiopharmaceuticals and contrast media administered by eviCore healthcare.
Reduced Services (CES) - Oxford Reimbursement Policy
Last Modified 03.01.2019
Effective Date: 03.01.2019 – 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 or facility.
Referrals – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date 04.01.2018 – This policy addresses referrals to a specialist, hospital, or ancillary provider.
Reimbursement for Comprehensive and Component CPT Codes (CES) – Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 03.01.2018 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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, 77387, 77402, 77407, 77412, 95941, 97014, 98970, 98971, 98972, G0455, G2061, G2062, G2063, G6001, G6002, G6003, G6007, G6011, G0453, G0283.
Repository Corticotropin Injection (H.P. Acthar Gel®) – Oxford Clinical Policy
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses the use of repository corticotropin injection (H.P. Acthar Gel®) for the treatment of infantile spasm, opsoclonus-myoclonus syndrome, and acute exacerbation of multiple sclerosis (MS). Applicable Procedure Code: J0800.
Requests for In-Network Exceptions – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date 09.01.2018 – This policy addresses the review of in-network exception requests for members residing within Oxford's service area.
Respiratory Interleukins (Cinqair®, Fasenra®, and Nucala®) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 03.01.2019 – 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
Last Modified 12.16.2019
Effective Date: 10.01.2019 – 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
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, and septal dermatoplasty. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30560, 30620.
Rituximab (Rituxan® & Truxima®) – Oxford Clinical Policy
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses the use of Rituxan® (rituximab) and Truxima® (rituximab-abbs) injection for intravenous infusion for the treatment of immune thrombocytopenic purpura (ITP), autoimmune mucocutaneous blistering diseases, Wegener’s granulomatosis and microscopic polyangiitis, autoimmune hemolytic anemia, chronic cold agglutinin disease, rheumatoid arthritis, post-transplant B-lymphoproliferative disorder, neuromyelitis optica, immunotherapy-related encephalitis, and thrombotic thrombocytopenic purpura (TTP). Applicable Procedure Codes: J9312, Q5115.
Robotic Assisted Surgery (CES) – Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses robotic-assisted surgery. Applicable Procedure Code: S2900.
Routine Foot Care – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – 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 (CES) – Oxford Reimbursement Policy
Last Modified 07.01.2019
Effective Date: 07.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 11.01.2019 – This policy addresses the use of Sandostatin LAR® (octreotide acetate LAR). Applicable Procedure Code: J2353.
Sensory Integration Therapy and Auditory Integration Training – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 09.01.2019 – 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
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses services and modifiers not reimbursable to healthcare professionals.
Services Requiring Prior Authorization – Oxford Administrative Policy
Last Modified 01.02.2020
Effective Date 01.01.2020 – This policy addresses services requiring prior authorization and their related policies.
Shoulder Replacement Surgery (Arthroplasty) – Oxford Clinical Policy
Last Modified 12.04.2019
Effective Date: 04.01.2019 – 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
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses Simponi Aria® (golimumab) injection for intravenous infusion for the treatment of ankylosing spondylitis, psoriatic arthritis, and rheumatoid arthritis. Applicable Procedure Code: J1602.
Site of Service Differential – Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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 Administrative Policy
Last Modified 11.22.2019
Effective Date: 08.01.2019 – This policy addresses skilled care and custodial care services. Applicable Procedure Codes: 99509, S5100, S5101, S5102, S5105, S5120, S5121, S5125, S5126, S5130, S5131, S5135, S5136, S5140, S5141, S5150, S5151, S5170, S5175, S9125, T1005, T1019, T1020.
Skin and Soft Tissue Substitutes – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses skin and soft tissue substitutes.
Sodium Hyaluronate – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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 Reimbursement Policy
Last Modified 04.01.2019
Effective Date: 04.01.2019 – 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, J3262, J3357, J3358, J3380, Q5103, Q5104.
Speech Therapy and Early Intervention Programs/Birth to Three – Oxford Administrative Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses the use of Spinraza™ (nusinersen) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J2326.
Split Surgical Package (CES) - Oxford Reimbursement Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses split surgical package situations.
Spravato™ (Esketamine) - Oxford Clinical Policy
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses the use of Spravato™ (esketamine) for the treatment of treatment-resistant depression (TRD). Applicable Procedure Code: J3490.
Standby Services – Oxford Reimbursement Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses standby services and hospital mandated on-call services. Applicable Procedure Codes: 99026, 99027, 99360.
Stelara® (Ustekinumab) – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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
Last Modified 11.04.2019
Effective Date: 11.04.2019 – This policy addresses codes representing supplies, drugs and other items based on the place of service (POS) submitted on the claim.
Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins - Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 09.01.2019 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 36465, 36466, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37780, 37799.
Surgical Treatment for Spine Pain – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses surgical treatment for spine pain.
Synagis® (Palivizumab) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 08.01.2019 – 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 (CES) – Oxford Reimbursement Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – 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 and Telemedicine (CES) - Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 04.01.2019 – This policy addresses telemedicine and telehealth services. Applicable Procedure Codes: 98966, 98967, 98968, 98969, 99441, 99442, 99443, 99444, T1014.
Temporomandibular Joint Disorders – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20605, 20606, 21010, 21050, 21060, 21085, 21089, 21110, 21240, 21242, 21243, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, E1702.
Thermography – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 04.01.2019 – 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 – Oxford Reimbursement Policy
Last Modified 01.21.2020
Effective Date: 01.21.2020 – This policy addresses time span codes.
Timeframe Standards for Benefit Administrative Initial Decisions – Oxford Administrative Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses initial benefit administrative decision and notification timeframes.
Timeframe Standards for Utilization Management (UM) Initial Decisions - Oxford Administrative Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses initial utilization management decision and notification timeframes.
Total Artificial Disc Replacement for the Spine – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899.
Total Artificial Heart – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 09.01.2019 – This policy addresses the SynCardia™ temporary total artificial heart. Applicable Procedure Codes: 33927, 33928.
Transcatheter Heart Valve Procedures – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral, tricuspid) procedures, including valve-in-valve procedures and transcatheter cerebral protection devices. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0569T, 0570T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33999, 93799.
Transcranial Magnetic Stimulation – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 02.01.2019 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.
Transpupillary Thermotherapy – Oxford Clinical Policy
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.
Trogarzo™ (Ibalizumab-Uiyk) - Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 04.01.2019 – This policy addresses the use of Trogarzo™ (ibalizumab-uiyk) for the treatment of multi-drug resistant human immunodeficiency virus (HIV). Applicable Procedure Code: J1746.
Umbilical Cord Blood Harvesting and Storage for Future Use – Oxford Clinical Policy
Last Modified 07.01.2019
Effective Date: 07.01.2019 – 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
Last Modified 11.22.2019
Effective Date: 08.01.2019 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.
Urgent Care – Oxford Reimbursement Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses services provided in an urgent care center. Applicable Procedure Codes: S9083, S9088.
Vaccines – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses vaccines/immunizations.
Vagus and External Trigeminal Nerve Stimulation – Oxford Clinical Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 64553, 64568, 64570, E0770, E1399, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Virtual Upper Gastrointestinal Endoscopy – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 09.01.2019 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Vision Services (Including Refractive Surgery) – Oxford Administrative Policy
Last Modified 11.22.2019
Effective Date: 09.01.2018 – This policy addresses the benefit and coverage considerations for vision services. Applicable Procedure Codes: 65205, 65210, 65220, 65222, 65430, 65435, 65600, 65760, 65765, 65767, 65771, 65778, 67820, 67938, 68040, 68761, 68801, 68810, 68840, 76510, 76511, 76512, 76513, 76514, 76516, 76519, 76529, 92002, 92004, 92012, 92014, 92015, 92230, 92235, 92250, 92260, 92287, 92310, 92313, 92314, 92326, 92340, 92341, 92342, 92354, 92370, S0592, S0595, S0596, S0620, S0621, S0800, S0810, S0812, V2600, V2610, V2615.
Visual Information Processing Evaluation and Orthoptic and Vision Therapy – Oxford Clinical Policy
Last Modified 12.01.2019
Effective Date: 12.01.2019 – 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.
Warming Therapy and Ultrasound Therapy for Wounds – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 10.01.2019 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 97610, A6000, E0231, E0232.
White Blood Cell Colony Stimulating Factors – Oxford Clinical Policy
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses the use of white blood cell colony stimulating factors (CSFs), including the drug products Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Udenyca, and Zarxio. Applicable Procedure Codes: J1442, J1447, J2505, J2820, Q5101, Q5108, Q5110, Q5111.
Whole Exome and Whole Genome Sequencing – Oxford Clinical Policy
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0012U, 0013U, 0014U, 0036U, 0094U, 81415, 81416, 81417, 81425, 81426, 81427.
Wrong Surgical or Other Invasive Procedures – Oxford Reimbursement Policy
Last Modified 11.22.2019
Effective Date: 06.01.2019 – This policy addresses wrong surgical or other invasive procedures performed on a patient.
Xolair® (Omalizumab) – Oxford Clinical Policy
Last Modified 11.22.2019
Effective Date: 09.01.2019 – This policy addresses the use of Xolair® (omalizumab) for subcutaneous use for the treatment of moderate to severe persistent asthma and chronic urticaria. Applicable Procedure Code: J2357.
Zolgensma® (Onasemnogene Abeparvovec-Xioi) – Oxford Clinical Policy
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses the use of Zolgensma® (onasemnogene abeparvovec-xioi) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Codes: C9399, J3490, J3590.
Zulresso™ (Brexanolone) – Oxford Clinical Policy
Last Modified 01.01.2020
Effective Date: 01.01.2020 – This policy addresses the use of Zulresso™ (brexanolone) for the treatment of postpartum depression (PPD) in adults. Applicable Procedure Codes: C9055, J3490, J3590.
Information regarding a policy or procedure that is not available online and copies of UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies can also be obtained by sending a written request to:
Oxford Policy Requests
4 Research Drive
Shelton, CT 06484
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.