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.
Last Published 10.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
Last Published 11.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
Last Published 12.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Oxford Clinical, Administrative, and Reimbursement Policies.
Last Published 12.01.2021
Current Policies
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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Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses intramuscular and subcutaneous injection of 17-alpha-hydroxyprogesterone caproate, commonly called 17P or Makena®. Applicable Procedure Codes: J1726, J1729, J2675.
Last Published 04.19.2021
Effective Date: 02.01.2021 – This policy addresses thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 27299, 64625, 64633, 64634, 64635, 64636, 64999.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the use of levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound ablation (MRgFUS), and ultrasound-guided radiofrequency ablation. Applicable Procedure Codes: 0071T, 0072T, 0404T, 37243, 58674, J7296, J7297, J7298, J7301, J7306, S4981.
Last Published 10.01.2021
Effective Date: 10.01.2021 – 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.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses accreditation requirements for radiologists, radiology centers, and multi-speciality provider groups interested in participating in the UnitedHealthcare Oxford network.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the exception process for the experimental/investigational treatment (drug therpay) of an acquired rare disease.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses the use of Actemra® (tocilizumab) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, systemic juvenile idiopathic arthritis, cytokine release syndrome, acute graft-versus-host disease, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J3262.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses acupuncture services. Applicable Procedure Codes: 20560, 20561, 997014, 97032, 97810, 97811, 97813, 97814, A4212, A4215, G0283, S8930.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of Adakveo® (crizanlizumab-tmca) to reduce the frequency of vasoocclusive crises in patients with sickle cell disease. Applicable Procedure Code: J0791.
Last Published 09.01.2021
Effective Date: 09.01.2021 – 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.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses reporting services of Advanced Practice Health Care Professionals, within a medical or other healthcare practice, to ensure submitted medical claims accurately identify the provider of service, including non-physician health care professionals.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses procedure codes for after hours and weekend care services. Applicable Procedure Codes: 99050, 99051, 99053, 99056, 99058, 99060.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses airway clearance devices, such as high-frequency chest wall oscillation systems, acoustical or mechanical percussor, positive expiratory pressure and aerosol drug delivery system combination device, and intrapulmonary percussive ventilation (IPV) devices. Applicable Procedure Codes: A7025, A7026, E0481, E0483, E1399.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®-C, and Zemaira®) for chronic augmentation and maintenance therapy of emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI)/alpha1-antitrypsin (AAT) deficiency. Applicable Procedure Codes: J0256, J0257.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.
Last Published 10.11.2021
Effective Date: 10.11.2021 – This policy addresses services included as part of an ambulance transportation service, ambulance modifier usage, provider specialty reporting ambulance services, and the requirements for reporting Advanced Life Support: Level 2 (ALS2) ambulance transportation.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses the use of Amondys 45™ (casimersen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1426.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses procedural or pain management services that are an integral part of anesthesia services, as well as anesthesia services that are an integral part of procedural services.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the use of antiemetics for prevention of chemotherapy-induced nausea and vomiting associated with anticancer agents. Applicable Procedures Codes: J0185, J1453, J1454, J1626, J1627, J2405, J2469, J8501, J8655, J8670, Q0162, Q0166.
Last Published 04.19.2021
Effective Date: 02.01.2021 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses autologous chondrocyte transplantation (ACT), osteochondral autograft and allograft transplantation, microfracture repair of the knee, and focal articular cartilage repair. Applicable Procedure Codes: 27412, 27415, 27416, 28446, 29866, 29867, 29879, J7330, S2112.
Last Published 06.01.2021
Effective Date: 06.01.2020 – This policy addresses assignment of benefits for services rendered by non-network providers and balance billing.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses services performed by an assistant for a physician performing a surgical procedure.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses assisted administration of clotting factors and coagulant blood products, including home health care services.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses home sleep apnea testing, attended full-channel nocturnal polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, and attended PAP titration. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses services for the treatment of autism spectrum disorder and developmental disabilities.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 27599.
Last Published 08.01.2021
Effective Date: 08.01.2021 – 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).
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298, 31299.
Last Published 04.19.2021
Effective Date: 12.01.2020 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, sleeve gastrectomy, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses hospital beds, mattresses, and accessories. Applicable Procedure Codes: E0193, E0194, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0271, E0272, E0273, E0274, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0305, E0310, E0315, E0316, E0328, E0329, E0910, E0911, E0912, E0940.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses behavioral health services for the treatment of mental health and substance use disorders.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of Benlysta® (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN). Applicable Procedure Code: J0490.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses unilateral procedures that can be performed on both sides of the body during the same session by the same individual physician or other qualified health care professional, including procedure codes with bilateral in their intent or "bilateral" in the description.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses upper and lower eyelid blepharoplasty, upper eyelid blepharoptosis repair, brow ptosis, eyelid surgery with an anophthalmic socket, ectropion or punctal eversion, entropion, lid retraction surgery, canthoplasty/canthopexy, and repair of floppy eyelid syndrome (FES).
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Applicable Procedure Codes: J0585, J0586, J0587, J0588.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses breast imaging, including digital mammography, magnetic resonance imaging (MRI), ultrasound, automated breast ultrasound system, computer-aided detection (CAD), computer-aided tactile breast imaging, electrical impedance scanning (EIS), magnetic resonance elastography (MRE), and molecular breast imaging. Applicable Procedure Codes: 0422T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 76376, 76377, 76391, 76498, 76499, 76641, 76642, 77046, 77047, 77048, 77049, 77065, 77066, 77067, S8080.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses breast reconstruction post-mastectomy and for treatment of Poland syndrome. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15771, 15772, 15777, 19301, 19302, 19303, 19305, 19306, 19307, 19316, 19318, 19325, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses the use of Brineura® (cerliponase alfa) in pediatric patients with late infantile neuronal ceroid lipofuscinosis (LINCL). Applicable Procedure Code: J0567.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the use of buprenorphine (Probuphine® and Sublocade®) for the treatment of opioid dependence/opioid use disorder. Applicable Procedure Codes: 11981, 11982, G0516, G0517, G0518, J0570, Q9991, Q9992.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0650T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272, 93285, 93291, 93298, E0616, G2066.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses cardiology procedures requiring precertification with initial review performed by eviCore healthcare.
Last Published 04.19.2021
Effective Date: 03.01.2021 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0052U, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses care plan oversight services as part of physician or other health care professional supervision of patients under the care of home health agencies, hospice, or nursing facilities.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 81412, 81443, 81479.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses catheter ablation for atrial fibrillation. Applicable Procedure Codes: 93653, 93655, 93656, 93657.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses the National Correct Coding Initiative (NCCI) edits not otherwise addressed in other UnitedHealthcare Oxford reimbursement policies for services reported together by the same individual physician or other health care professional for the same member on the same date of service that may be eligible for separate reimbursement.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 81420, 81422, 81479, 81507.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses genome-wide comparative genomic hybridization microarray testing or single nucleotide polymorphism (SNP) chromosomal microarray analysis. Applicable Procedure Codes: 0156U, 0209U, 81228, 81229, 81479, S3870.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses the use of Cimzia® (certolizumab pegol) the treatment of Crohn’s disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, and plaque psoriasis. Applicable Procedures Codes: 96372, 96401, J0717.
Last Published 01.01.2021
Effective Date: 01.01.2021 – This policy addresses recovery of claim overpayments.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses laboratory services under the Clinical Laboratory Improvement Amendment (CLIA) 1988 statute and regulations.
Last Published 02.01.2021
Effective Date: 02.01.2021 – This policy addresses the review of clinical information for the purposes of determining eligibility of coverage, prior authorization of medical services, and claim payment.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses clotting factors and coagulant blood products. Applicable Procedure Codes: J7170, J7175, J7177, J7178, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7192, J7193, J7194, J7195, J7198, J7199, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7212.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses co-surgeon and team surgeon services.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses the use of Soliris® (eculizumab) and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: J1300, J1303.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses computer-assisted surgical navigation for musculoskeletal procedures and the use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty. Applicable Procedures Codes: 0054T, 0055T, 20985.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses consultation services. Applicable Procedure Codes: 99446, 99447, 99448, 99449, 99451, 99452, G0406, G0407, G0408, G0425, G0426, G0427, G0508, G0509.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4211, A4226, A9274, A9276, A9277, A9278, E0784, E0787, E1399, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.
Last Published 02.15.2021
Effective Date: 09.01.2020 – This policy addresses contraceptive procedures/appliances/devices and injectable drugs provided in a physician’s office.
Last Published 03.01.2021
Effective Date: 03.01.2021 – This policy addresses the order in which insurance plans pay claims when an individual has coverage under more than one plan.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses measurement of corneal hysteresis, measurement of ocular blood flow, and monitoring of intraocular pressure. Applicable Procedure Codes: 0198T, 0329T, 66999, 67299, 92145.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses cosmetic and reconstructive procedures.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses credentialing guidelines for radiologists and cardiologists interested in participating in the eviCore healthcare network.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses the use of Crysvita® (burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH) and Fibroblast Growth Factor 23 (FGF23)-related hypophosphatemia in tumor-induced osteomalacia (TIO). Applicable Procedure Code: J0584.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses deep brain stimulation and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the use of denosumab (Prolia® & Xgeva®). Applicable Procedure Code: J0897.
Last Published 04.01.2021
Effective Date: 04.01.2021 – This policy addresses oral surgical and dental procedures and related anesthesia when determined to be medical in nature.
Last Published 06.01.2021
Effective Date: 01.01.2021 – This policy addresses coding guidelines associated with reporting devices, implants, and skin substitutes with their associated procedures for outpatient hospital services.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses supplies, medications, and equipment for the treatment of diabetes.
Last Published 03.01.2021
Effective Date: 03.01.2021 – This policy addresses dialysis services. Applicable Procedure Codes: 90935, 90937, 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90967, 90968, 90969, 90970, 90989, 90993, 90997, 90999, G0257, G0491, G0492.
Last Published 02.15.2021
Effective Date: 09.01.2020 – This policy addresses certain information disclosed to members regarding their claims for benefits covered under their certificates or appeals of adverse benefit determinations.
Last Published 04.19.2021
Effective Date: 12.01.2020 – This policy addresses thermal intradiscal procedures (TIPs) and percutaneous discectomy and decompression procedures for treating discogenic pain, and annulus fibrosus repair following spinal surgery. Applicable Procedure Codes: 22526, 22527, 22899, 62287, 62380, S2348.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses surgical and diagnostic procedures terminated at the direction of a health care professional, including the use of modifier 53 (discontinued procedure).
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses medications for which certain types of prescription drug benefit exclusions may apply.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses multiple drug coverage guidelines.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses the daily limit for presumptive and definitive drug testing, and specimen validity testing.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses rental and/or purchase of certain items of durable medical equipment (DME), prosthetics, and orthotics.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Last Published 04.19.2021
Effective Date: 01.01.2021 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses electrical stimulation and electromagnetic therapy for wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Applicable Procedure Codes: 0278T, 63650, 63655, 63663, 63664, 63685, 64555, 64566, 64999, E0744, E0745, E0762, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Last Published 07.07.2021
Effective Date: 07.01.2021 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the use of Eloctate™ [antihemophilic factor (recombinant), FC fusion protein] for the treatment of Hemophilia A. Applicable Procedure Codes: J7199, J7205.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses level 4 and level 5 evaluation and management (E/M) codes when billed for services rendered in an emergency department. Applicable Procedures Codes: 99284, 99285, 99291, 99292, G0383, G0384.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses emergency room visits, including services provided outside of the United States.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of Entyvio® (vedolizumab) for the treatment of Crohn's disease, ulcerative colitis, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J3380.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses epidural steroid injections for spinal pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses functional anesthetic discography (FAD), provocative discography, epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions for the diagnosis or treatment of any type of neck, back, or spinal disorder. Applicable Procedure Codes: 62263, 62264, 62290, 62291, 62292, 64999, 72285, 72295.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the use of erythropoiesis-stimulating agents (ESAs), including Aranesp® (darbepoetin alfa), Epogen® (epoetin alfa), Mircera® (methoxy polyethylene glycol-epoetin beta [MPG-epoetin beta]), Procrit® (epoetin alfa), and Retacrit™ (epoetin alfa). Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses evaluation and management (E/M) services.
Last Published 04.19.2021
Effective Date: 12.01.2020 – This policy addresses the use of Evenity® (romosozumab- aqqg) for the treatment of osteoporosis in postmenopausal patients at high risk for fracture. Applicable Procedures Code: J3111.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses the use of Evkeeza (evinacumab-dgnb) for the treatment of homozygous familial hypercholesterolemia (HoFH). Applicable Procedure Code: J1305.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses experimental and/or investigational treatment or procedures for New Jersey (NJ) Plans.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses experimental and/or investigational treatment or procedures.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses extended benefits for totally disabled members, including when a member changes carriers while confined in an inpatient facility.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses facet joint injections/medial branch blocks for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.
Last Published 06.01.2021
Effective Date: 12.01.2019 – This policy addresses timeframes for submission of original claims, additional information, and appeals.
Last Published 11.01.2021
Effective Date: 11.01.2021 – 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.
Last Published 02.02.2021
Effective Date: 10.01.2020 – This policy addresses follow-up care when rendered in an emergency room (ER) site of service/setting.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses specialized formula and foods, including enteral formulas, nutritional formulas, and pasteurized donor human milk. Applicable Procedure Codes: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9432, S9433, S9434, S9435, T2101.
Last Published 10.11.2021
Effective Date: 10.11.2021 – This policy addresses the "from" and "to" dates reported on claims.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Last Published 04.19.2021
Effective Date: 01.01.2021 – This policy addresses the use of Gamifant® (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses gastric electrical stimulation therapy; manometry, sensation, tone, and compliance testing; defecography; and electrogastrography/electroenterography. Applicable Procedure Codes: 43647, 43648, 43881, 43882, 64590, 64595, 72195, 72196, 72197, 76496, 91117, 91120, 91122, 91132, 91133.
Last Published 04.19.2021
Effective Date: 03.01.2021 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 0097U, 87505, 87506, 87507.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 0216U, 0217U, 81440, 81460, 81465, 81479.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses genitourinary pathogen nucleic acid detection panel testing to evaluate symptomatic women for vaginitis. Applicable Procedure Codes: 0068U, 87480, 81513, 81514, 87481, 87482, 87510, 87511, 87512, 87660, 87661, 87797, 87798, 87799, 87800, 87801.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and gonioscopy-assisted transluminal trabeculotomy. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 65820, 66174, 66175, 66179, 66180, 66183, 66184, 66185, C1889, L8612.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the timeframe (global days) that applies to certain procedures subject to a global surgical package concept whereby all necessary services normally furnished by a physician (before, during, and after the procedure) are included in the reimbursement for the procedure performed.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products. Applicable Procedure Codes: J1950, J1951, J3315, J3316, J9155, J9202, J9217, J9225, J9226.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of C1 esterace inhibitors (human), C1 esterace inhibitors (recombinant), and plasma kallikrein inhibitors (human) for the treatment and prophlaxis of hereditary angioedema (HAE). Applicable Procedure Codes: J0596, J0597, J0598, J1290.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses home health care services.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses services included as part of an ambulance transportation service and ambulance modifier usage. Applicable Procedure Codes: A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses human menopausal gonadotropins (hMG), including Menopur® (menotropins for injection). Applicable Procedure Codes: S0122, S4042.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses the use of Ilaris® (canakinumab) for the treatment of cryopyrin-associated periodic syndromes (CAPS), tumor necrosis factor (TNF) receptor-associated periodic syndrome (TRAPS), hyperimmunoglobulin D (Hyper-IgD) syndrome (HIDS)/mevalonate kinase deficiency (MKD), familial mediterranean fever (FMF), Still’s disease, and systemic juvenile idiopathic arthritis (SJIA). Applicable Procedure Code: J0638.
Last Published 04.19.2021
Effective Date: 02.01.2021 – This policy addresses the use of provider-administered Ilumya™ (tildrakizumab-asmn) for the treatment of moderate to severe plaque psoriasis. Applicable Procedure Code: J3245.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, J1459, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses hospital outpatient facility infusion services for intravenous immune globulin (IVIG) and subcutaneous immune globulin (SCIG) therapy. Applicable Procedure Codes: 90283, 90284, J1459, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599, J3590.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of malignant tumors. Applicable Procedure Codes: 37243, 79445, S2095.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses implanted electrical stimulator for spinal cord. Applicable Procedure Codes: 63650, 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses implanted spinal drug delivery systems for the treatment of cancer-related pain, severe spasticity, and chronic non-malignant pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses in-network exceptions for breast reconstruction surgery after mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19316, 19325, 19330, 19340, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, 19396, 19499, 19318, L8600, S2066, S2067, S2068, S8950.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses laboratory testing/procedures that Oxford Network physicians may provide in their offices, including specimen handling and venipuncture.
Last Published 06.01.2021
Effective Date: 06.01.2021 – 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).
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses diagnostic and therapeutic procedures for infertility and cryopreservation.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses the use of infliximab products, including Avsola™ (infliximab-axxq), Inflectra® (infliximab-dyyb), Remicade® (infliximab), and Renflexis® (infliximab-abda). Applicable Procedure Codes: J1745, Q5103, Q5104, Q5109, Q5121.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses the use of inhaled nitric oxide (iNO) for treating term or near-term infants with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN). Applicable Procedure Code: 94799.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses therapeutic and diagnostic injection and infusion services when reported with evaluation and management (E/M) services, including related supplies and/or drugs.
Last Published 04.19.2021
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.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses inpatient readmissions of members to the same facility for the same or related condition on the same date of service, planned readmissions, and leave of absence readmissions within 30 days.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses diagnosis codes which should not be billed as the principal diagnosis on claims.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the use of intensity-modulated radiation therapy (IMRT). Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses intraoperative neuromonitoring (IONM) services. Applicable Procedure Codes: 92653, 95822, 95860, 95861, 95863 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95925, 95926, 95927, 95928, 95929, 95930, 95933, 95937, 95938, 95939, 95940, G0453.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses intrauterine fetal surgery (IUFS) and fetoscopic endoluminal tracheal occlusion (FETO) . Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of intravenous enzyme replacement drug products for the treatment of Gaucher disease, including Cerezyme® (imiglucerase), Elelyso® (taliglucerase), and VPRIV® (velaglucerase). Applicable Procedure Codes: J1786, J3060, J3385.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses the use of intravenous iron replacement therapy with Feraheme® (ferumoxytol), Injectafer® (ferric carboxymaltose), and Monoferric® (ferric derisomaltose) for the treatment of iron deficiency anemia (IDA) with and without chronic kidney disease (CKD). Applicable Procedure Codes: J1437, J1439, Q0138.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the use of Krystexxa® (pegloticase) for treatment of chronic gout refractory to conventional therapy. Applicable Procedure Code: J2507.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses laboratory services, including laboratory panels, venipuncture services, laboratory services performed in a facility setting, laboratory handling, surgical pathology, clinical pathology consultations, and drug assay codes.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses respiratory viral panels of 6 or more pathogens. Applicable Procedure Codes: 0115U, 0151U, 0202U, 0223U, 0225U, 87632, 87633.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 64999.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Lemtrada (alemtuzumab) for treatment of relapsing forms of multiple sclerosis. Applicable Procedure Code: J0202.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 17106, 17107, 17108, 17380.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses liposuction for lipedema when used to treat functional impairment. Applicable Procedure Codes: 15877, 15878, 15879.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses the use of Cabenuva (cabotegravir/rilpivirine) for the treatment of a human immunodeficiency virus type-1 (HIV-1) in patients who are virologically suppressed. Applicable Procedure Code: J0741.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses lower extremity vascular angiography and endovascular revascularization procedures. Applicable Procedure Codes: 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235, 75710, 75716.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the use of Luxturna™ (voretigene neparvovec-rzyl) for the treatment of inherited retinal dystrophies (IRD) caused by mutations in the retinal pigment epithelium-specific protein 65kDa (RPE65) gene. Applicable Procedure Code: J3398.
Last Published 04.19.2021
Effective Date: 12.01.2020 – This policy addresses the use of parenteral antibiotics for treating Lyme disease. Applicable Procedure Codes: J0558, J0561, J0696, J0698, J2510, J2540.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses implantable miniature telescope (IMT), conjunctival incision with posterior extrascleral placement of a pharmacologic agent, laser photocoagulation, and radiation therapy. Applicable Procedure Codes: 0308T, 67036, 67299, 92499.
Last Published 04.19.2021
Effective Date: 02.01.2021 – This policy addresses advanced radiologic imaging procedures performed in a hospital outpatient department.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses manual wheelchairs.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.
Last Published 10.11.2021
Effective Date: 10.11.2021 – This policy addresses maximum frequency per day determinations for services/procedures.
Last Published 04.19.2021
Effective Date: 01.01.2021 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses drug products used as medical therapies for enzyme deficiency. Applicable Procedure Codes: C9399, J0180, J0221, J1322, J1458, J1743, J1931, J2840, J3397, J3490, J3590.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the process and timeframes of an administrative grievance/appeal.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses use of an operating microscope during a surgical procedure. Applicable Procedure Codes: 64727, 69990.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Mifeprex® (mifepristone) in combination with misoprostol for medical termination of intrauterine pregnancy. Applicable Procedure Codes: S0190, S0191.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD) and the Per Oral Endoscopic Myotomy (POEM) procedure for achalasia or diffuse esophageal spasm. Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43499, 43999.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses other reimbursement policies in which modifiers are addressed.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses reimbursement for claims appended with modifier SU.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses Mohs micrographic surgery, including excision and pathology services. Applicable Procedure Codes: 17311, 17312, 17313, 17314, 17315.
Last Published 11.01.2021
Effective Date: 10.01.2021 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses when multiple diagnostic cardiovascular procedures or diagnostic ophthalmology procedures are performed on the same day.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses multiple procedure payment reduction (MPPR) when multiple diagnostic imaging procedures are performed in a single session.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses multiple medical or surgical procedures performed on the same day by the same group physician and/or other health care professional.
Last Published 04.19.2021
Effective Date: 03.01.2021 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy. Applicable Procedure Codes: 55899, 64999.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses nerve conduction studies and other neurophysiological testing.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses neuropsychological testing and computerized cognitive testing under the medical benefit. Applicable Procedure Codes: 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses new patient visits. Applicable Procedure Codes: 92002, 92004, 99202, 99203, 99204, 99205, 99324, 99325, 99326, 99327, 99328, 99341, 99342, 99343, 99344, 99345, 99381, 99382, 99383, 99384, 99385, 99386, 99387, G0245, G0438, S0610, S0620.
Last Published 06.01.2021
Effective Date: 03.01.2020 – This policy addresses enrollment and coverage of newborns.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses nonphysician health care professional service codes. Applicable Procedure Codes: 0650T, 96040, 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171, 97802, 97803, 97804, 98960, 98961, 98962, 99605, 99606, 99607, G0270, G0271, G2251.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses evaluation and management (E/M) services reported by nonphysician health care professionals.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses observation care services and discharge day management. Applicable Procedure Codes: 99217, 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, 99236, 99238, 99239.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses observation services in a hospital setting.
Last Published 10.11.2021
Effective Date: 10.11.2021 – This policy addresses global obstetrical (OB) codes and itemization of maternity care services. Applicable Procedure Codes: 59400, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59525, 59610, 59612, 59614, 59618, 59620, 59622, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99417, G2212, S0273, S0274.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses obstetrical ultrasounds. Applicable Procedure Codes: 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76818, 76819, 76820, 76821, 76825, 76826, 76827, 76828.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T,0436T, 0466T, 0467T, 0468T, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, E0485, E0486, K1001, K1027, L8679, L8680, L8686, S2080, S2900.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses occipital neuralgia and headache treatments, including occipital nerve blocks and occipital nerve ablation. Applicable Procedure Codes: 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64633, 64634, 64722, 64744, 64771, 64999, K1023, L8679, L8680, L8685.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses the use of Ocrevus® (ocrelizumab) for the treatment of multiple sclerosis. Applicable Procedure Code: J2350.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses certain elective procedures that are typically performed in an office setting but may be performed in an ambulatory surgical center in certain circumstances. Applicable Procedure Codes: 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11442, 19000, 20552, 20553, 27096, 31579, 57460, 62270, 62321, 64479, 64490, 64493, 64633, 64635.
Last Published 11.18.2021
Effective Date: 10.01.2021 – This policy addresses multiple services/procedures.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses certain procedures reimbursed only once during a patient’s lifetime.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Codes: J0640, J0641, J0642, J1950, J3315, J9035, J9155, J9198, J9199, J9201, J9202, J9217, J9218, J9219, J9310, J9312, J9316, J9355, J9356, Q5107, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119.
Last Published 10.01.2021
Effective Date: 10.01.2021 – 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.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses the use of Onpattro® (patisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedures Code: J0222.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses the use of Orencia® (abatacept) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, psoriatic arthritis, chronic graft-versus-host disease, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J0129.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses orthognathic (jaw) surgery.
Last Published 05.11.2021
Effective Date: 05.01.2021 – This policy addresses services subject to utilization review with OrthoNet’s orthopedic division.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses neonatal hearing screening, auditory screening, and diagnostic testing using otoacoustic emissions (OAEs). Applicable Procedure Codes: 92558, 92587, 92588.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses reimbursement of claims submitted with a from and to date range, including reporting valid dates of service for each claim line.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses add-on codes when used to bill for services rendered at an outpatient hospital.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses outpatient blood and blood products, including transfusion, irradiation, freezing, thawing, and splitting services, and packed red blood cells and whole blood. Applicable Procedures Codes: 86945, 86985, P9011.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses National Correct Coding Initiative (NCCI) edits not otherwise addressed in other reimbursement policies in order to determine whether CPT and/or HCPCS codes reported together by the outpatient hospital for the same member on the same date of service are eligible for separate reimbursement.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses diagnosis codes which should never be billed as primary on an outpatient hospital claim.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses maximum frequency per day units for outpatient hospital services.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses outpatient hospital observation services. Applicable Procedures Codes: G0378, G0379.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses outpatient medical visits when submitted in addition to other procedure codes, when in circumstances when multiple medical visit codes are submitted, and when trauma activation occurs in addition to critical care services.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses outpatient physical and occupational therapy services managed by OptumHealth Care Solutions.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses outpatient physical therapy (PT), occupational therapy (OT), and speech-language pathology (ST) services.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses the medical necessity of certain planned surgical procedures when performed in a hospital outpatient department.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses self-referral for outpatient imaging services.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses the use of Oxlumo™ (Lumasiran) for the treatment of primary hyperoxaluria type 1 (PH1). Applicable Procedure Code: J0224.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.
Last Published 06.01.2021
Effective Date: 05.01.2020 – This policy addresses participating gastroenterologists located in New York performing non-emergent procedures using nonparticipating anesthesiologists in office (IO) or in an ambulatory surgery center (ASC).
Last Published 08.24.2021
Effective Date: 05.01.2020 – This policy addresses participating providers treating a member on a Connecticut (CT) or New York (NY) product and wants to use a non-participating laboratory/pathologist or wants to provide the member with a form to obtain laboratory/pathology services outside the physician office.
Last Published 06.01.2021
Effective Date: 05.01.2020 – This policy addresses a participating provider's use of a non-participating provider physician, facility, or other healthcare provider in a member’s care, and the Member Advanced Notice Form.
Last Published 06.01.2021
Effective Date: 05.01.2020 – This policy addresses participating surgeons located in New York using non-participating assistant surgeons and co-surgeons for non-emergent procedures.
Last Published 06.01.2021
Effective Date: 05.01.2020 – This policy addresses participating providers in New York and Connecticut using non-participating providers for intraoperative neuro-monitoring (IONM).
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses patient lifts. Applicable Procedure Codes: E0621, E0625, E0630, E0635, E0636, E0639, E0640, E1035, E1036.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses pediatric and neonatal critical and intensive care services. Applicable Procedure Codes: 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, 99480.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses pediatric gait trainers, standing systems, and walkers. Applicable Procedure Codes: A4636, A4637, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158, E0159, E0637, E0638, E0641, E0642, E8000, E8001, E8002.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses pediatric outpatient intensive feeding programs. Applicable Procedure Code: 92526.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses percutaneous neuroablation for the treatment of severe cancer pain and trigeminal neuralgia. Applicable Procedure Codes: 64605, 64610, 64620, 64640.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke. Applicable Procedure Code: 93580.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses percutaneous vertebroplasty and kyphoplasty for treating spinal pain. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515.
Last Published 11.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of pharmacogenetic multi-gene panel testing for genetic polymorphisms. Applicable Procedure Codes: 0029U, 0078U, 0173U, 0175U, 81479.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses reimbursement for the Practice Expense (PE) portions of certain therapy procedures when those services are the secondary or subsequent procedures provided on a single date of service by the same group physician and/or other health care professional.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses physical and occupational therapy evaluation services and the use of the GO, GP, CO, and CQ modifiers.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses CPT codes from the Physical Medicine and Rehabilitation, Evaluation and Management, Adaptive Behavior Assessment and other sections of the CPT Manual that will not be reimbursed when reported by Speech-Language Therapists/Pathologists.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses physical, occupational, speech, and cognitive therapy, and therapeutic manipulation for New Jersey Small Group members.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses the use of cranial orthotic devices for treating infants following craniosynostosis surgery or for nonsynostotic (nonfusion) deformational or positional plagiocephaly. Applicable Procedure Codes: 21175, D5924, L0112, L0113, S1040.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy adddresses power mobility devices.
Last Published 01.01.2021
Effective Date: 01.01.2021 – This policy addresses the process and timeframes for participating practitioner and provider administrative claims appeals brought on their own behalf.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses preimplantation genetic testing (PGT). Applicable Procedure Codes: 0254U, 81228, 81229, 81479.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses preventive care services.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses preventive medicine and screening services.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses services which are exempt from the standard outpatient precertification requirement.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses private duty nursing (PDN) services. Applicable Procedure Code: T1000.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses procedure codes that include the place of service (POS) in their description or where coding guidelines are provided relative to POS.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the appropriate use of modifiers with individual CPT and HCPCS procedure codes.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses services with professional and/or technical component indicators, as well as information pertaining to duplicate/repeat services, modifier usage, services based on place of service (POS), and the professional component with an evaluation and management service.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses prolonged services when reported in conjunction with companion evaluation and management (E/M) codes or other services. Applicable Procedure Codes: 99354, 99355, 99356, 99357, 99358, 99359, 99415, 99416, 99417, 99484, 99487, 99489, 99490, 99491, 99492, 99493, 99494, 99495, 99496, G0513, G0514, G2058, G2212.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, 0481T, G0460, M0076, P9020, S9055.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses prostrate surgeries and interventions, including transurethral ablation, cryoablation, surgical prostatectomy, prostatic urethral lift (PUL), high-energy water vapor thermotherapy, and transperineal placement of biodegradable material.
Last Published 10.01.2021
Effective Date: 10.01.2021– This policy addresses prosthetic devices, specialized/computerized/myoelectric limbs, and wigs, and includes applicable procedure codes for breast prosthesis, ear/eye/nose/facial prosthesis, lower and upper limb prosthetics, additions to upper extremity, prosthetic socks, repairs and replacements, and wigs.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses outpatient hospital facility-based intravenous medication infusion. Applicable Procedure Codes: C9399, J0129, J0180, J0221, J0222, J0223, J0224, J0256, J0257, J0490, J0517, J0584, J0638, J0717, J0741, J0791, J0896, J0897, J1300, J1301, J1303, J1305, J1322, J1426, J1427, J1428, J1429, J1458, J1602, J1743, J1745, J1746, J1786, J1823, J1931, J2182, J2786, J2840, J3032, J3060, J3241, J3245, J3262, J3357, J3358, J3380, J3385, J3397, J3490, J3590, Q5103, Q5104, Q5121.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses radiation therapy fractionation, image-guided radiation therapy (IGRT), and special radiation therapy services. Applicable Procedure Codes: 77014, 77331, 77370, 77385, 77386, 77387, 77399, 77401, 77402, 77407, 77412, 77470, 77520, 77522, 77523, 77525, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of Radicava® (edaravone) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses radiology procedures which require precertification by eviCore healthcare, including computerized axial tomography (CAT) scan, CT colonography/virtual colonoscopy (for diagnostic purposes), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), nuclear medicine imaging, positron emission tomography (PET) scans, and obstetrical ultrasound.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses radiopharmaceuticals and contrast media administered by eviCore healthcare.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses Reblozyl® (luspatercept-aamt) for the treatment of anemia in adult patients with beta thalassemia and symptomatic anemia in patients with myelodysplastic sydromes or myleodysplastic/myeloproliferative neoplasms. Applicable Procedure Code: J0896.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses edit sources used identifying and combining specific coding relationships into the most comprehensive and/or appropriate procedure code, including when services are considered incidental, mutually exclusive, transferred, or unbundled.
Last Published 12.01.2021
Effective Date: 12.01.2021 – 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.
Last Published 11.01.2021
Effective Date: 07.01.2021 – This policy addresses referrals to a specialist, hospital, or ancillary provider.
Last Published 06.01.2021
Effective Date: 03.01.2020 – This policy addresses the payment methodology utilized by Oxford in determining claims reimbursement when multiple procedures are performed in the same session by the same provider.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses specific codes assigned status code "I" on the National Physician Fee Schedule (NPFS) where the Centers for Medicare and Medicaid Services (CMS) has indicated a replacement code is available and has assigned a Relative Value Unit (RVU) to the replacement code. Applicable Procedure Codes: 44705, 77387, 77402, 77407, 77412, 95941, 97014, 99417, G0283, G0453, G0455, G2212, G6001, G6002, G6003, G6007, G6011.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of repository corticotropin injection (Acthar® Gel) for the treatment of infantile spasm, opsoclonus-myoclonus syndrome, and acute exacerbation of multiple sclerosis (MS). Applicable Procedure Code: J0800.
Last Published 09.01.2020
Effective Date: 09.01.2020 – This policy addresses the review of in-network exception requests for members residing within Oxford's service area.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the use of interleukin-5 (IL-5) antagonists, including Cinqair® (reslizumab), Fasenra® (benralizumab), and Nucala® (mepolizumab). Applicable Procedure Codes: J0517, J2182, J2786.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, septal dermatoplasty, and nasal polypectomy. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30560, 30620, 31237.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses the use of Riabni™ (rituximab-arrx), Rituxan® (rituximab), Ruxience® (rituximab-pvvr), and Truxima® (rituximab-abbs). Applicable Procedure Codes: J9311, J9312, Q5115, Q5119, Q5123.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses robotic-assisted surgery. Applicable Procedure Code: S2900.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses routine foot care for members with diabetes or who are at risk for neurological or vascular disease arising from diseases such as diabetes.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses Ryplazim® (plasminogen, human-tvmh) for the treatment of plasminogen deficiency type 1 (hypoplasminogenemia). Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses sacroiliac joint interventions, including sacroiliac joint injections and sacroiliac joint fusion. Applicable Procedure Codes: 27096, 27279, 27280, 64451, G0260.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses multiple medical and/or evaluation and management (E/M) services for a patient on a single date of service.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the use of Sandostatin LAR® (octreotide acetate LAR). Applicable Procedure Code: J2353.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses Saphnelo™ (anifrolumab-fnia) for the treatment of moderate to severe systemic lupus erythematosus (SLE). Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses Scenesse® (afamelanotide) for the treatment of erythropoietic protoporphyria (EPP). Applicable Procedures Code: J7352.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses planned preventive screening colonoscopies performed in a hospital outpatient department. Applicable Procedures Codes: 45378, 45380, 45381, 45384, 45385, G0105, G0121.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses services and modifiers not reimbursable to healthcare professionals.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses reporting the services provided as “incident-to” a supervising health care provider, including shared and split evaluation and management services.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses services requiring prior authorization and their related policies.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses Simponi Aria® (golimumab) injection for intravenous infusion for the treatment of ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis. Applicable Procedure Code: J1602.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses a site of service differential that reduces practice expense payments for services provided in facility or ambulance settings.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses skilled care and custodial care services. Applicable Procedure Codes: 99509, S5100, S5101, S5102, S5105, S5120, S5121, S5125, S5126, S5130, S5131, S5135, S5136, S5140, S5141, S5150, S5151, S5170, S5175, S9125, T1005, T1019, T1020.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses skin and soft tissue substitutes.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses intra-articular injections of sodium hyaluronate. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.
Last Published 06.01.2021
Effective Date: 10.01.2020 – This policy addresses certain specialty medications provided in an outpatient hospital setting that must be obtained from the designated specialty pharmacy. Applicable Procedure Codes: J0129, J0202, J0717, J1602, J1745, J2323, J2350, J2507, J3262, J3357, J3358, J3380, Q5103, Q5104.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses speech generating devices. Applicable Procedure Codes: E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599.
Last Published 04.19.2021
Effective Date: 09.01.2020 – This policy addresses speech therapy and early intervention/birth to three programs. Applicable Procedure Codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92610, 92626, 92627, 92700, G0153, H2014, H2015, H2019, S9128, S9152, T1015, T1023, T1024, T1025, T1026, T1027, T1028, T2024.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses spinal fusion enhancement products. Applicable Procedure Codes: 20930, 20931, 22899.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses the use of Spinraza® (nusinersen) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J2326.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses split surgical package situations.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses the use of Spravato® (esketamine) for the treatment of treatment-resistant depression (TRD) and major depressive disorder (MDD). Applicable Procedure Codes: J3490, S0013.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses standby services and hospital mandated on-call services. Applicable Procedure Codes: 99026, 99027, 99360.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses the use of Stelara® (ustekinumab) for the treatment of Crohn’s disease, plaque psoriasis, psoriatic arthritis, and ulcerative colitis. Applicable Procedure Codes: J3357, J3358.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses stereotactic radiation therapy, including stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). Applicable Procedures Codes: 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77371, 77372, 77373, 77432, 77435, G0339, G0340.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses codes representing supplies, drugs, and other items based on the place of service (POS) submitted on the claim.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses surgery of the ankle. Applicable Procedure Codes: 27685, 27700, 27702, 27703, 27704, 29891, 29892, 29894, 29895, 29897, 29898, 29899.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses surgery of the elbow. Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24366, 24370, 24371, 29830, 29834, 29837, 29838.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses surgery of the foot. Applicable Procedure Codes: 28285, 28289, 28291, 28292, 28295, 28297, 28298, 28299, 28296, 28299, 29893.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses surgery of the hand or wrist. Applicable Procedure Codes: 25280, 25332, 25441, 25442, 25443, 25444, 25445, 25446, 25447, 25449, 26530, 26531, 26535, 26536, 29840, 29843, 29844, 29845, 29846, 29847.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses surgery of the hip and femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 29860, 29861, 29862, 29863, 29914, 29915, 29916, 29999, S2118.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses surgery of the knee. Applicable Procedure Codes: 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 29850, 29851, 29855, 29856, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses surgery of the shoulder. Applicable Procedure Codes: 23412, 23470, 23472, 23473, 23474, 29805, 29806, 29807, 29819, 29820, 29822, 29823, 29824, 29825, 29826, 29827, 29828.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 36465, 36466, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses surgical treatment for spine pain.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the use of a sympathetic blockade using a local anesthetic. Applicable Procedure Codes: 64510, 64517, 64520, 64530.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the use of Synagis® (palivizumab) to prevent serious respiratory syncytial virus disease (RSV) in high risk infants and young children. Applicable Procedure Code: 90378.
Last Published 06.01.2021
Effective Date: 02.08.2021 – This policy addresses procedure codes assigned a "T" status indicator on the National Physician Fee Schedule (NPFS) by the Centers for Medicare and Medicaid Services (CMS). Applicable Procedure Codes: 36598, 94760, 94761, 96523, G0117, G0118.
Last Published 06.01.2021
Effective Date: 04.19.2021 – This policy addresses telemedicine and telehealth services.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20552, 20553, 20605, 20606, 21010, 21050, 21060, 21070, 21085, 21089, 21110, 21198, 21209, 21240, 21242, 21243, 21247, 21299, 21499, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, E1702.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Code: J3241.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses thermography, including digital infrared thermal imaging, temperature gradient studies, and magnetic resonance (MR) thermography. Applicable Procedure Codes: 76498, 93740.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses time span codes.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses initial benefit administrative decision and notification timeframes.
Last Published 07.23.2021
Effective Date: 05.01.2020 – This policy addresses initial utilization management decision and notification timeframes.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899.
Last Published 11.01.2021
Effective Date: 11.01.2021 – This policy addresses the SynCardia™ temporary Total Artificial Heart. Applicable Procedure Codes: 33927, 33928, 33975, 33976, 33979, 33981, 33982, 33983, 33995, 33997.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 0646T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33999, 93799.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses transcutaneous electrical nerve stimulator (TENS), including supplies and conductive garments. Applicable Procedure Codes: A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731, E0762, K1023.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of Trogarzo® (ibalizumab-uiyk) for the treatment of multi-drug resistant human immunodeficiency virus (HIV). Applicable Procedure Code: J1746.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of Tysabri® (natalizumab) for the treatment of relapsing forms of multiple sclerosis and Crohn's disease. Applicable Procedure Code: J2323.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses Uplizna® (inebilizumab-cdon) for the treatment of neuromyelitis optica spectrum disorder (NMOSD). Applicable Procedures Code: J1823.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses services provided in an urgent care center. Applicable Procedure Codes: S9083, S9088.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses vaccines/immunizations.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 64553, 64568, 64570, E0770, E1399, K1016, K1017, K1020, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Codes: 0656T, 0657T, 22899.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses Viltepso® (viltolarsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Codes: J1427.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Last Published 01.01.2021
Effective Date: 01.01.2021 – This policy addresses the benefit and coverage considerations for vision services.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 92065, 92499.
Last Published 04.19.2021
Effective Date: 01.01.2021 – This policy addresses the use of Vyepti™ (Eptinezumab) for the treatment of chronic and episodic migraine. Applicable Procedure Code: J3032.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of Vyondys 53™ (golodirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1429.
Last Published 04.19.2021
Effective Date: 01.01.2021 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 97610, A6000, E0231, E0232.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy adddresses wheelchair options and accessories.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy adddresses wheelchair seating. Applicable Procedure Codes: E0953, E0955, E0956, E0957, E0960, E0966, E0992, E1028, E2231, E2291, E2292, E2293, E2294, E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2610, E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2619, E2620, E2621, E2622, E2623, E2624, E2625, K0108, K0669.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses the use of white blood cell colony stimulating factors (CSFs), including the drug products Fulphila™, Granix®, Leukine®, Neulasta® , Neupogen®, Nivestym™, Nyvepria™, Udenyca™, Zarxio®, and Ziextenzo™. Applicable Procedure Codes: J1442, J1447, J2505, J2820, JQ5101, Q5108, Q5110, Q5111, Q5120, Q5122.
Last Published 10.01.2021
Effective Date: 10.01.2021 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0012U, 0013U, 0014U, 0036U, 0094U, 0212U, 0213U, 0214U, 0215U, 0265U, 81415, 81416, 81417, 81425, 81426, 81427.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses wrong surgical or other invasive procedures performed on a patient.
Last Published 04.19.2021
Effective Date: 04.01.2021 – This policy addresses the use of Xiaflex® (collagenase clostridium histolyticum) for the treatment of Dupuytren’s contracture and Peyronie’s disease. Applicable Procedure Codes: 20527, 26341, J0775.
Last Published 12.01.2021
Effective Date: 12.01.2021 – This policy addresses the use of Xolair® (omalizumab) for subcutaneous use for the treatment of moderate to severe persistent asthma, chronic urticaria, and nasal polyps. Applicable Procedure Code: J2357.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses the use of Zulresso™ (brexanolone) for the treatment of postpartum depression (PPD) in adults. Applicable Procedure Code: J1632.
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.
To submit new or additional clinical evidence pertaining to a specific medical policy, click here to complete a form for UnitedHealthcare Medical Policy review. Do not submit protected health information using this form. If you have questions or concerns about a specific service for a member, refer to the appropriate Benefits, Claims, or Prior Authorization/Notification process.