The Medical Policies, Medical Benefit Drug Policies, and corresponding update bulletins for UnitedHealthcare Individual Exchange Plans are listed below.
A monthly notice of recently approved and/or revised Medical Policies and Medical Benefit Drug 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 Medical Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Medical Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
Last Published 04.01.2025
Last Published 05.01.2025
Last Published 06.01.2025
Last Published 06.01.2025
UnitedHealthcare has developed Medical Policies and Medical Benefit Drug Policies to assist us in administering health benefits. These policies and guidelines are provided for informational purposes, and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
Our Medical Policies and Medical Benefit Drug Policies express our determination of whether a health service (e.g., test, drug, device, or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered
Benefit coverage for health services is determined by the member specific benefit plan document, such as a Certificate of Coverage, Schedule of Benefits, or Summary Plan Description, and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these policies and guidelines.
Medical Policies and Medical Benefit Drug Policies are developed as needed, regularly reviewed and updated, and subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies and guidelines is believed to be accurate and current as of the date of publication and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, such as the InterQual® criteria, to assist us in administering health benefits. UnitedHealthcare Medical Policies and Medical Benefit Drug Policies are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
UnitedHealthcare's Medical Policies and Medical Benefit Drug Policies do not include notations regarding prior authorization requirements. View the services that are subject to notification/prior authorization requirements.
Medical Policies and Medical Benefit Drug Policies are the property of UnitedHealthcare. Unauthorized copying, use, and distribution of this information are strictly prohibited. The InterQual® criteria are proprietary to Change Healthcare and are not published on this website.
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Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses Intraosseous radiofrequency ablation, ablation for treating sacroiliac pain, and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 27299, 64625, 64628, 64629.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses endometrial ablation, 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, 37243, 58563, J7296, J7297, J7298, J7301, J7306, S4981.
Last Published 06.01.2025
Effective Date: 06.01.2025 – 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 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Adzynma (ADAMTS13, recombinant-krhn) for the treatment of congenital thrombotic thrombocytopenic purpura (cTTP). Applicable Procedure Code: J7171.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses airway clearance devices, such as high-frequency chest wall oscillation systems, and intrapulmonary percussive ventilation (IPV) devices. Applicable Procedure Codes: A7021, A7025, A7026, E0469, E0481, E0483.
Last Published 11.01.2024
Effective Date: 11.01.2024 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Amondys 45® (casimersen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1426.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of antiemetics for prevention of chemotherapy-induced nausea and vomiting associated with anticancer agents. Applicable Procedures Codes: J0185, J1434, J1453, J1454, J1456, J1626, J1627, J2405, J2468, J2469, J8501, J8655, J8670, Q0162, Q0166.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 0717T, 0718T, 27599.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses bariatric surgical procedures. Applicable Procedure Codes: 0813T, 43290, 43291, 43644, 43645, 43647, 43648, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43847, 43848, 43860, 43865, 43881, 43882, 43886, 43887, 43888, 43999, 64590, 64595, 64999.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses hospital beds, mattresses, and accessories. Applicable Procedure Codes: E0193, E0194, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0277, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0305, E0310, E0316, E0328, E0329, E0910, E0911, E1399.
Last Published 11.01.2024
Effective Date: 11.01.2024 – 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 03.01.2025
Effective Date: 03.01.2025 – 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, J0589.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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, S8080.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses breast reconstruction post-mastectomy and for the treatment of Poland syndrome, removal of breast implants, and breast repair and reconstruction not post mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15771, 15772, 15777, 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Last Published 11.01.2024
Effective Date: 11.01.2024 – 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 12.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Briumvi® (ublituximab-xiiy) for the treatment of relapsing forms of multiple sclerosis (MS). Applicable Procedure Code: J2329.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.
Last Published 06.02.2025
Effective Date: 05.01.2025 – This policy addresses brow ptosis, browpexy or internal browlift, eyelid surgery for correction of lagophthalmos, lid retraction surgery, and canthoplasty/canthopexy. Applicable Procedure Codes: 15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of buprenorphine (Brixadi® & Sublocade®) for the treatment of opioid dependence/opioid use disorder. Applicable Procedure Codes: J0577, J0578, Q9991, Q9992.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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, long-chain omega-3 fatty acids, and multi-protein biomarkers. Applicable Procedure Codes: 0019M, 0052U, 0308U, 0309U, 0377U, 0415U, 83695, 83698, 83701, 83704, 93050, 93799, 93895, and 93998.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 0400U, 81412, 81443, 81479.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Category III codes.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses catheter ablation for atrial fibrillation. Applicable Procedure Codes: 93653, 93655, 93656, 93657.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0488U, 0489U, 0494U, 0536U, 81422, 81479.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J3520, J8499, M0300, S9355.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses chemotherapy observation or overnight (inpatient) stay.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses genome-wide comparative genomic hybridization microarray testing or single nucleotide polymorphism (SNP) chromosomal microarray analysis. Applicable Procedure Codes: 0156U, 0209U, 81228, 81229, 81349, 81479, S3870.
Last Published 02.01.2025
Effective Date: 02.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses clotting factors and coagulant blood products. Applicable Procedure Codes: C9304, J3490, J3590, 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, J7213, J7214.
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of PiaSky® (crovalimab-akkz), Soliris® (eculizumab), and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: J1299, J1303, J1307.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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, 27599.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4226, A4238, A4239, A9274, A9276, A9277, A9278, E0784, E0787, E2102, E2103, S1030, S1031, S1034, S1035, S1036, S1037.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Cosentyx® (secukinumab) for the treatment of psoriatic arthritis (PsA), ankylosing spondylitis (AS), and non-radiographic axial spondyloarthritis (nr-axSpA). Applicable Procedure Code: J3247.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses cosmetic and reconstructive procedures.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses deep brain stimulation and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61889, 61891, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of denosumab (Jubbonti®, Prolia®, Wyost®, and Xgeva®). Applicable Procedure Codes: J0897, Q5136.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses dynamic spinal visualization techniques and vertebral motion analysis. Applicable Procedure Codes: 0693T, 76120, 76125, 76496, 76499.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses spinal and paraspinal ultrasonography. Applicable Procedure Code: 76800.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses annular closure devices (ACDs), percutaneous injection of allogeneic cellular/tissue-based products, and thermal intradiscal procedures (TIPs) for treating discogenic pain. Applicable Procedure Codes: 0627T, 0628T, 0629T, 0630T, 22526, 22527, 22899, S2348.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses the use of edaravone for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation, including transcutaneous electrical nerve stimulator (TENS), functional electrical stimulation (FES), and neuromuscular electrical stimulation (NMES). Applicable Procedure Codes: 0278T, 0720T, 0783T, 63650, 63655, 63663, 63664, 63685, 64555, 64596, 64597, 64598, 64999, A4438, A4543, A4544, A4556, A4557, A4593, A4594, A4595, E0720, E0721, E0730, E0731, E0743, E0744, E0745, E0764, E0770, E1399, L8678, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses electromagnetic therapy for wounds. Applicable Procedure Codes: E0769, G0295, G0329.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses multifocal electroretinogram (mfERG), pattern electroretinogram (PERG), and pattern electroretinogram optimized for glaucoma screening (PERGLA). Applicable Procedure Codes: 0509T, 92274.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Elevidys™ (delandistrogene moxparvovec-rokl) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1413.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of Enjaymo® (sutimlimab-jome) for the treatment of cold agglutinin disease (CAD). Applicable Procedure Code: J1302.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses enteral nutrition, including enteral formulas and low protein modified food products. Applicable Procedure Codes: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9432, S9433, S9434, S9435.
Last Published 06.01.2024
Effective Date: 06.01.2024 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses epidural steroid injections for spinal pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 04.01.2025
Effective Date: 04.01.2025 – 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 11.01.2024
Effective Date: 11.01.2024 – 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 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of Evkeeza® (evinacumab-dgnb) for the treatment of homozygous familial hypercholesterolemia (HoFH). Applicable Procedure Code: J1305.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.
Last Published 06.01.2025
Effective Date: 05.01.2025 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 0864T, 28890.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses companion diagnostic testing for oncology indications. Applicable Procedure Codes: 0022U, 0037U, 0179U, 0239U, 0242U, 0473U, 0543U, 81445, 81449, 81450, 81451, 81455, 81456, 81479, 81599.
Last Published 12.01.2024
Effective Date: 12.01.2024 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses gastric electrical stimulation therapy; manometry, sensation, tone, and compliance testing; defecography; and electrogastrography/electroenterography. Applicable Procedure Codes: 0779T, 0868T, 43647, 43648, 43881, 43882, 64590, 64595, 72195, 72196, 72197, 74270, 76496, 91117, 91120, 91122, 91132, 91133, A9286, A9900, A9999, E1399.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 0369U, 87505, 87506, 87507.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of Hemgenix® (etranacogene dezaparvovec-drlb) for the treatment of hemophilia B. Applicable Procedure Codes: J1411, J1414.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 0401U, 0439U, 0440U, 0466U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing. Applicable Procedure Codes: 0101U, 0102U, 0103U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0138U, 0162U, 0238U, 0474U, 0475U, 81162, 81163, 81164, 81165, 81166, 81167, 81216, 81432, 81433, 81435, 81436, 81437, 81438, 81441, 81479.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 0216U, 0217U, 81440, 81460, 81465, 81479.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and gonioscopy-assisted transluminal trabeculotomy. Applicable Procedure Codes: 0253T, 0449T, 0450T, 0474T, 0671T, 65820, 66174, 66175, 66179, 66180, 66183.
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products. Applicable Procedure Codes: J1950, J1951, J1952, J1954, J3315, J3316, J9155, J9202, J9217, J9226.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses outpatient habilitation, rehabilitation and maintenance therapy.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 12.01.2024
Effective Date: 12.01.2024 – This policy addresses the use of C1 esterace inhibitors (human), C1 esterace inhibitors (recombinant), and plasma kallikrein inhibitors (human) for the treatment and prophylaxis of hereditary angioedema (HAE). Applicable Procedure Codes: J0596, J0597, J0598, J1290.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses home health, skilled, and custodial care services.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses hospital services for observation versus inpatient level of care.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses hyperbaric oxygen therapy (HBOT) and topical oxygen therapy (TOT). Applicable Procedure Codes: 99183, A4575, E0446, G0277.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.
Last Published 12.01.2024
Effective Date: 12.01.2024 – 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 06.01.2025
Effective Date: 06.01.2025 – 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 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, J1459, J1551, J1552, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599.
Last Published 06.01.2025
Effective Date: 05.01.2025 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0650T, 0902T, 33285, 33286, 93285, 93291, 93297, 93298, 93799, E0616, E1399.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses implanted electrical spinal cord and dorsal root ganglion (DRG) stimulation. Applicable Procedure Codes: 63650, 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses services for infertility and fertility preservation.
Last Published 01.01.2025
Effective Date: 0.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses dermal filler injections and injectable bulking agents. Applicable Procedure Codes: G0429, L8607, Q2026, Q2028.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of interspinous bony fusion devices and interspinous decompression systems. Applicable Procedure Codes: 22853, 22854, 22859, 22867, 22868, 22869, 22870, 22899.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of specialty pharmacy medications administered by the intravitreal route for certain ophthalmologic conditions. Applicable Procedure Codes: J1096, J7311, J7312, J7313, J7314.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 06.01.2025
Effective Date: 06.01.2025 – 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 03.01.2025
Effective Date: 03.01.2025 – 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, Q0139.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Ketalar® (ketamine) for anesthesia purposes and Spravato® (esketamine) for the treatment of treatment-resistant depression (TRD) and major depressive disorder (MDD). Applicable Procedure Codes: J3490, S0013.
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Kisunla™ (donanemab-azbt) for the treatment of Alzheimer’s disease (AD). Applicable Procedure Code: J0175.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Korsuva® (difelikefalin) for the treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis. Applicable Procedure Code: J0879.
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Krystexxa® (pegloticase) for treatment of chronic gout refractory to conventional therapy. Applicable Procedure Code: J2507.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses closure (occlusion) of the left atrial appendage (LAA). Applicable Procedure Codes: 33267, 33268, 33340.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of Lemtrada® (alemtuzumab) for treatment of relapsing forms of multiple sclerosis. Applicable Procedure Code: J0202.
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Leqembi® (lecanemab-irmb) for the treatment of Alzheimer’s disease (AD). Applicable Procedure Code: J0174.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of Leqvio® (inclisiran) for the treatment of heterozygous familial hypercholesterolemia (HeFH) and clinical atherosclerotic cardiovascular disease (ASCVD). Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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: 0479T, 0480T, 17106, 17107, 17108, 17999, 96999.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses liposuction for lipedema when used to treat functional impairment. Applicable Procedure Codes: 15877, 15878, 15879.
Last Published 01.01.2025
Effective Date: 01.01.2025 – 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 Codes: J0739, J0741, J1961.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses endovascular revascularization procedures. Applicable Procedure Codes: 0238T, 0505T, 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of lower extremity prosthetic for amputations, endoskeletal knee-shin system with microprocessor control, and combined microprocessor-controlled ankle foot system with power assist.
Last Published 11.01.2024
Effective Date: 11.01.2024 – 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 05.01.2025
Effective Date: 05.01.2025 – 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, 0378T, 0379T, 67036, 67299, 92499.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses advanced radiologic imaging procedures performed in a hospital outpatient department.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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, E1803, E1804, E1806, E1807, E1808, E1810, E1811, E1812, E1813, E1814, E1815, E1816, E1818, E1822, E1823, E1826, E1827, E1828, E1829, E1830, E1831, E1832, E1841.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses drug products used as medical therapies for enzyme deficiency. Applicable Procedure Codes: J0180, J0219, J0221, J1203, J1322, J1458, J1743, J1931, J2840, J3397.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD) and the Per Oral Endoscopic Myotomy (POEM) procedure for achalasia or diffuse esophageal spasm. Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43497, 43499, 43999.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses minimally invasive spine surgery procedures. Applicable Procedure Codes: 0200T, 0201T, 0275T, 22586, 22630, 22899, 62287, 62380, G0276.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses molecular oncology testing for hematologic cancer. Applicable Procedure Codes: 0017M, 0050U, 0120U, 0171U, 0298U, 0299U, 0300U, 0331U, 0364U, 0413U, 0485U, 81195, 81450, 81451, 81455, 81456, 81479, 81599.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, prostate cancer, thyroid cancer, hematological cancer, lung cancer, and solid tumor cancers.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses the use of Rystiggo®, Vyvgart®, & Vyvgart® Hytrulo for the treatment of myasthenia gravis. Applicable Procedure Codes: J9332, J9333, J9334.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses nerve conduction studies and other neurophysiological testing.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Niktimvo™ (axatilimab-csfr) for the treatment of chronic graft-versus-host disease (cGVHD). Applicable Procedure Code: J9038.
Last Published 05.08.2025
Effective Date: 05.01.2025 – This policy addresses warming therapy, noncontact normothermic wound therapy, noncontact real-time fluorescence wound imaging, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 0598T, 0599T, 97610, A6000, E0231, E0232.
Last Published 06.01.2025
Effective Date: 05.01.2025 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 21142, 21199, 21206, 21685, 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 41512, 41530, 41599, 42140, 42145, 42299, 64570, 64582, 64583, 64584, 93150, 93151, 93152, 93153, A7049, E0485, E0486, E0492, E0493, E0530, E1399, K1027, L8679, L8680, L8686, S2080, S2900.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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, 64596, 64597, 64598, 64633, 64634, 64722, 64744, 64771, 64999, A4540, L8679, L8680, L8685.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of Ocrevus® (ocrelizumab) for the treatment of multiple sclerosis. Applicable Procedure Codes: J2350, J2351.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses instrument-based ocular photoscreening and retinal birefringence scanning/retinal polarization scanning. Applicable Procedure Codes: 0469T, 99174, 99177.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses multiple services/procedures.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Omvoh® (mirikizumab-mrkz) injections for the treatment of ulcerative colitis. Applicable Procedure Code: J2267.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Codes: A9513, A9590, A9606, A9607, A9699, C9142, J0640, J0641, J0642, J1323, J1950, J1954, J3263, J9022, J9035, J9119, J9202, J9205, J9206, J9217, J9228, J9271, J9292, J9294, J9296, J9297, J9299, J9304, J9305, J9310, J9311, J9312, J1914, J9316, J9322, J9355, J9356, J9324, J9380, Q5107, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5123, Q5126.
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses the use of Izervay™ (avacincaptad pegol) and Syfovre™ (pegcetacoplan injection) for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Applicable Procedure Codes: J2781, J2782.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of vascular endothelial growth factor (VEGF) inhibitors. Applicable Procedure Codes: J0177, J0178, J0179, J2778, J9035, Q5124, Q5147.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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, immune checkpoint inhibitor-related toxicities and the prophylaxis of acute graft-versus-host disease. Applicable Procedure Code: J0129.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses orthognathic (jaw) surgery.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the medical necessity of certain planned surgical procedures when performed in a hospital outpatient department.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Oxlumo® (lumasiran) and Rivfloza™ (nedosiran) for the treatment of primary hyperoxaluria type 1 (PH1). Applicable Procedure Codes: C9399, J0224, J3490.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses percutaneous neuroablation for the treatment of severe cancer pain and trigeminal neuralgia. Applicable Procedure Codes: 64600, 64605, 64610, 64620, 64640.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke. Applicable Procedure Code: 93580.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses percutaneous vertebroplasty and kyphoplasty for treating spinal pain. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of pharmacogenetic multi-gene panel testing for genetic polymorphisms. Applicable Procedure Codes: 0029U, 0078U, 0173U, 0175U, 0345U, 0347U, 0348U, 0349U, 0350U, 0392U, 0411U, 0419U, 0423U, 0434U, 0438U, 0460U, 0461U, 0533U, 81418, 81479.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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: D5924, L0112, L0113, S1040.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses pneumatic, advanced intermittent pneumatic and intermittent limb compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses preimplantation genetic testing (PGT) and related services. Applicable Procedure Codes: 0254U, 58970, 58974, 76948, 81228, 81229, 81349, 81479, 89250, 89251, 89253, 89254, 89255, 89257,89258, 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89342, 89352, S4011, S4015, S4016, S4022, S4037.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses preventive care services.
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses vaccines/immunizations.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses private duty nursing services. Applicable Procedure Code: T1000.
Last Published 05.01.2025
Effective Date: 05.01.2025– This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, G0460, G0465, M0076, P9020.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses prostrate surgeries and interventions, including transurethral ablation, cryoablation, Radical prostatectomy, prostatic urethral lift (PUL), high-energy water vapor thermotherapy, Transurethral water jet ablation, and transperineal placement of biodegradable material. Applicable Procedure Codes: 0421T, 0582T, 0619T, 0655T, 0714T, 0738T, 0739T, 0867T, 37243, 52441, 52442, 53850, 53852, 53854, 53855, 53865, 53866, 55873, 55874.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses the use of Qalsody® (tofersen) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1304.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses radiation therapy fractionation, image-guided radiation therapy (IGRT), and special radiation therapy services.
Last Published 06.02.2025
Effective Date: 06.01.2025 – This policy addresses Reblozyl® (luspatercept-aamt) for the treatment of anemia in adult patients with beta thalassemia and symptomatic anemia in patients with myelodysplastic syndromes or myleodysplastic/myeloproliferative neoplasms. Applicable Procedure Code: J0896.
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of Rebyota® (fecal microbiota, live-jslm) for prevention of the recurrence of clostridioides difficile infection (CDI). Applicable Procedure Code: J1440.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of repository corticotropin injections (Acthar® Gel and Purified Cortophin Gel™). Applicable Procedure Codes: J0801, J0802.
Last Published 01.01.2025
Effective Date: 01.01.2025 – 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 06.01.2025
Effective Date: 06.01.2025 – This policy addresses respiratory pathogen nucleic acid detection testing. Applicable Procedure Codes: 0115U, 0202U, 0223U, 0225U, 87632, 87633.
Last Published 05.15.2025
Effective Date: 12.01.2024 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, septal dermatoplasty, nasal polypectomy, nasal septal swell body reduction, and nasal implants . Applicable Procedure Codes: 30117, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30469, 31237, 64999, L8699.
Last Published 01.01.2025
Effective Date: 01.01.2025 – 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 06.01.2025
Effective Date: 06.01.2025 – This policy addresses the use of Amvuttra® (vutrisiran) and Onpattro® (patisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedures Codes: C9399, J0222, J3490, J3590.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of Roctavian® (valoctocogene roxaparvovec-rvox) for the treatment of Hemophilia A (factor VIII Deficiency). Applicable Procedure Code: J1412.
Last Published 03.01.2025
Effective Date: 03.01.2025 – This policy addresses Ryplazim® (plasminogen, human-tvmh) for the treatment of plasminogen deficiency type 1 (hypoplasminogenemia). Applicable Procedure Code: J2998.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses sacral nerve stimulation for urinary and fecal indications. Applicable Procedure Codes: 0784T, 0785T, 0786T, 0787T, 64561, 64581, 64585, 64590, 64595, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses sacroiliac joint interventions, including sacroiliac joint injections and sacroiliac joint fusion. Applicable Procedure Codes: 27096, 27278, 27279, 27280, 64451, G0260.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses Saphnelo® (anifrolumab-fnia) for the treatment of moderate to severe systemic lupus erythematosus (SLE). Applicable Procedure Code: J0491.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses Scenesse® (afamelanotide) for the treatment of erythropoietic protoporphyria (EPP). Applicable Procedures Code: J7352.
Last Published 05.01.2025
Effective Date: 05.01.2025 – 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 08.01.2024
Effective Date: 08.01.2024 – This policy addresses medications that are determined to be self-administered and excluded from medical coverage.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.
Last Published 03.01.2025
Effective Date: 03.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses balloon sinus ostial dilation, functional endoscopic sinus surgery (FESS), and self-expanding absorptive sinus ostial dilation. Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 31298, 31299.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses skin and soft tissue substitutes.
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses the intravenous use of Skyrizi® (risankizumab-rzaa) injection for the treatment of Crohn’s disease (CD). Applicable Procedures Code: J2327.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses home sleep apnea testing, attended full-channel polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, attended PAP titration and attended repeat testing. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
Last Published 06.01.2025
Effective Date: 06.01.2024 – 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 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of somatostatin analogs, including Sandostatin® (octreotide acetate), Sandostatin® LAR (octreotide acetate LAR), Signifor® (pasireotide diaspartate), Signifor® LAR (pasireotide), and Somatuline® Depot (lanreotide). Applicable Procedure Codes: J1930, J1932, J2353, J2354, J2502.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Spevigo® (spesolimab-sbzo) for the treatment of generalized pustular psoriasis (GPP). Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses spinal fusion enhancement products. Applicable Procedure Codes: 0814T, 20930, 20931, 20939, 22899.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses spinal fusion and decompression procedures, laminectomy, isolated facet fusion, dynamic stabilization systems, and total facet joint arthroplasty.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses the use of Spinraza® (nusinersen) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J2326.
Last Published 12.01.2024
Effective Date: 03.01.2024 – 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 05.01.2025
Effective Date: 05.01.2025 – 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, G0563.
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses the use of compounded implantable drug pellets. Applicable Procedure Codes: 11981, 11982, 11983, J3490, J7999.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses surgical procedures for the treatment or prevention of lymphedema. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 38999, 49906.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses surgery of the ankle. Applicable Procedure Codes: 27685, 27700, 27702, 27703, 27704, 28446, 28899, 29891, 29892, 29894, 29895, 29897, 29898, 29899.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses surgery of the elbow. Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24366, 24370, 24371, 29830, 29834, 29835, 29836, 29837, 29838.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses surgery of the foot. Applicable Procedure Codes: 28285, 28289, 28291, 28292, 28295, 28297, 28298, 28299, 28296, 28299, 28899, 29893.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses surgery of the hand or wrist. Applicable Procedure Codes: 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 29840, 29843, 29844, 29845, 29846, 29847.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses surgery of the hip and femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 29860, 29861, 29862, 29863, 29914, 29915, 29916, 29999, S2118.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses surgery of the knee. Applicable Procedure Codes: 0737T, 27412, 27415, 27416, 27418, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27568, 27569, 27664, 27665, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, G0428, J7330, S2112.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses surgery of the shoulder. Applicable Procedure Codes: 23470, 23472, 23473, 23474, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of a sympathetic blockade using a local anesthetic. Applicable Procedure Codes: 64510, 64517, 64520, 64530.
Last Published 10.01.2024
Effective Date: 10.01.2024 – 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 03.01.2025
Effective Date: 03.01.2025 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Code: J3241.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of injectable testosterone and testosterone pellets for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone. Applicable Procedure Codes: 11980, J1071, J3121, J3145, S0189.
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses the use of Tezspire® (tezepelumab) for the treatment of severe asthma. Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 04.01.2025
Effective Date: 04.01.2025 – This policy addresses the use of tocilizumab (Actemra®, Tofidence™, and Tyenne®) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, systemic juvenile idiopathic arthritis, giant cell arteritis, cytokine release syndrome, acute graft-versus-host disease, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Codes: J3262, Q5133, Q5135.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0098T, 0165T, 22856, 22857, 22858, 22860, 22861, 22862, 22899.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses transarterial radioembolization (TARE)/selective internal radiation therapy (SIRT) using yttrium-90 microspheres for the treatment of malignant cancers of the liver. Applicable Procedure Codes: 37243, 75984, 79445, S2095.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 0646T, 0805T, 0806T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33370, 33418, 33419, 33477, 93799.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 0858T, 0889T, 0890T, 0891T, 0892T, 90867, 90868, 90869.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20552, 20553, 20605, 20606, 21010, 21050, 21060, 21070, 21085, 21089, 21110, 21240, 21242, 21243, 21247, 21299, 21499, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, and E1702.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Tremfya® (guselkumab)for the treatment of ulcerative colitis. Applicable Procedure Code: J1628.
Last Published 06.01.2025
Effective Date: 06.01.2025 – 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 04.01.2025
Effective Date: 04.01.2025 – 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 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Tzield® (teplizumab-mzwv) to delay the onset of stage 3 type 1 diabetes. Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses Uplizna® (inebilizumab-cdon) for the treatment of neuromyelitis optica spectrum disorder (NMOSD). Applicable Procedures Code: J1823.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses upper extremity myoelectric prosthetic devices. Applicable Procedure Codes: L6026, L6028, L6029, L6030, L6031, L6032, L6033, L6037, L6611, L6621, L6629, L6632, L6677, L6680, L6682, L6686, L6687, L6688, L6694, L6695, L6696, L6697, L6698, L6700, L6715, L6880, L6881, L6882, L6883, L6884, L6890, L6925, L6935, L6945, L6955, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, L7259, L7360, L7364, L7366, L7367, L7368, L7400, L7401, L7403, L7404, L7406, and L8465.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 61886, 64553, 64568, 64570, A4541, E0733, E0735, E0770, E1399, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses the use of Veopoz® (pozelimab-bbfg) for the treatment of CD55-deficient protein-losing enteropathy (PLE) (i.e., CHAPLE disease). Applicable Procedure Codes: C9399, J3490, and J3590.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Codes: 0656T, 0657T, 0790T, 22836, 22837, 22838, 22899.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses video electroencephalographic (EEG) monitoring and recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses Viltepso® (viltolarsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1427.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 0687T, 0688T, 0704T, 0705T, 0706T, 92065, 92066, 92499.
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses the use of Vyepti® (Eptinezumab) for the treatment of chronic and episodic migraine. Applicable Procedure Code: J3032.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses the use of Vyjuvek® (beramagene geperpavec-svdt) for the treatment of wounds in patients with dystrophic epidermolysis bullosa (DEB). Applicable Procedure Code: J3401.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses the use of Vyondys 53® (golodirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1429.
Last Published 06.01.2025
Effective Date: 06.01.2025 – This policy addresses the use of walkers. Applicable Procedure Codes: A4636, A4637, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0152, E0154, E0155, E0156, E0157, E0158, E0159, E1399.
Last Published 04.01.2025
Effective Date: 04.01.2025 – 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, J1449, J2506, J2820, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5127, Q5130, Q5148.
Last Published 05.01.2025
Effective Date: 05.01.2025 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0094U, 0212U, 0213U, 0214U, 0215U, 0260U, 0264U, 0265U, 0266U, 0267U, 0335U, 0336U, 0425U, 0426U, 0454U, 0469U, 0532U, 81415, 81416, 81417, 81425, 81426, 81427.
Last Published 01.01.2025
Effective Date: 01.01.2025 – 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 08.01.2024
Effective Date: 08.01.2024 – 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 12.01.2024
Effective Date: 12.01.2024 – This policy addresses the use of Zolgensma® (onasemnogene abeparvovec-xioi) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J3399.
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.