The Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, Utilization Review Guidelines, and corresponding update bulletins for UnitedHealthcare Value & Balance Exchange Plans are listed below.
A monthly notice of recently approved and/or revised Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines (CDGs), and Utilization Review Guidelines (URGs) 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 06.01.2021
Last Published 07.01.2021
Last Published 08.03.2021
Please read the terms and conditions below carefully.
UnitedHealthcare has developed Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines 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
Coverage Determination Guidelines are used to determine whether a service falls within a benefit category or is excluded from coverage. Coverage Determination Guidelines may address such matters as whether services are skilled versus custodial, or reconstructive versus cosmetic.
Utilization Review Guidelines apply clinical practice guidelines to determine whether the health care services provided or planned for an individual member are the most appropriate and cost-effective services under the specific circumstances.
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, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines are developed as needed, are regularly reviewed and updated, and are 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, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines 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, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines do not include notations regarding prior authorization requirements. View the services that are subject to notification/prior authorization requirements.
Medical Policies, Medical Benefit Drug Policies Coverage Determination Guidelines, and Utilization Review Guidelines are the property of UnitedHealthcare. Unauthorized copying, use, and distribution of this information are strictly prohibited. The InterQual® criteria are proprietary to InterQual® and are not published on this website.
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Last Published 10.01.2020
Effective Date: 01.01.2021 – 17-Alpha-Hydroxyprogesterone Caproate (Makena® and 17P) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 03.01.2021 – Ablative Treatment for Spinal Pain – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Abnormal Uterine Bleeding and Uterine Fibroids – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Actemra® (Tocilizumab) Injection for Intravenous Infusion – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Adakveo® (Crizanlizumab-Tmca) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Airway Clearance Devices – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Alpha1-Proteinase Inhibitors – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Ambulance Services – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Amondys 45™ (Casimersen) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Anti-Thymocyte Globulin (Lymphocyte Immune Globulin) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Antiemetics for Oncology – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Antithrombin III (ATryn®, Thrombate III®) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 03.01.2021
Effective Date: 03.01.2021 – Apheresis – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Apokyn® (Apomorphine) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Articular Cartilage Defect Repairs, Knee – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Athletic Pubalgia Surgery – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Attended Polysomnography for Evaluation of Sleep Disorders – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Autologous Cellular Therapy for Certain Indications – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Balloon Sinus Ostial Dilation – Value & Balance Exchange Medical Policy
Last Published 03.01.2021
Effective Date: 03.01.2021 – Bariatric Surgery – Value & Balance Exchange Medical Policy
Last Published 05.10.2021
Effective Date: 04.01.2021 – Beds and Mattresses – Value & Balance Exchange Coverage Determination Guideline
Last Published 04.01.2021
Effective Date: 04.01.2021 – Benlysta® (Belimumab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair – Value & Balance Exchange Coverage Determination Guideline
Last Published 10.01.2020
Effective Date: 01.01.2021 – Bone or Soft Tissue Healing and Fusion Enhancement Products – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Boniva® (Ibandronate) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 04.01.2021 – Botulinum Toxins A and B – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.14.2020
Effective Date: 01.01.2021 – Breast Imaging for Screening and Diagnosing Cancer – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Breast Reconstruction Post Mastectomy and Poland Syndrome – Value & Balance Exchange Coverage Determination Guideline
Last Published 05.01.2021
Effective Date: 05.01.2021 – Breast Reduction Surgery – Value & Balance Exchange Coverage Determination Guideline
Last Published 02.01.2021
Effective Date: 02.01.2021 – Breast Repair/Reconstruction Not Following Mastectomy – Value & Balance Exchange Coverage Determination Guideline
Last Published 08.01.2021
Effective Date: 08.01.2021 – Brineura® (Cerliponase Alfa) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Bronchial Thermoplasty – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Buprenorphine (Probuphine® & Sublocade®) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Cardiac Event Monitoring – Value & Balance Exchange Medical Policy
Last Published 03.01.2021
Effective Date: 03.01.2021 – Cardiovascular Disease Risk Tests – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Carrier Testing for Genetic Diseases – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Catheter Ablation for Atrial Fibrillation – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Cell-Free Fetal DNA Testing – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Ceprotin® (Protein C Concentrate) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Chelation Therapy for Non-Overload Conditions – Value & Balance Exchange Medical Policy
Last Published 11.17.2020
Effective Date: 01.01.2021 – Chemosensitivity and Chemoresistance Assays in Cancer – Value & Balance Exchange Medical Policy
Last Published 05.06.2021
Effective Date: 05.01.2021 – Chemotherapy Observation or Inpatient Hospitalization – Value & Balance Exchange Utilization Review Guideline
Last Published 06.01.2021
Effective Date: 06.01.2021 – Chromosome Microarray Testing (Non-Oncology Conditions) – Value & Balance Exchange Medical Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Cimzia® (Certolizumab Pegol) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Clinical Trials – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Cochlear Implants – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Cognitive Rehabilitation – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Collagen Crosslinks and Biochemical Markers of Bone Turnover – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Complement Inhibitors (Soliris® & Ultomiris®) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 12.28.2020
Effective Date: 01.01.2021 – Computed Tomographic Colonography – Value & Balance Exchange Medical Policy
Last Published 12.17.2020
Effective Date: 01.01.2021 – Computer-Assisted Surgical Navigation for Musculoskeletal Procedures – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Computerized Dynamic Posturography – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Value & Balance Exchange Medical Policy
Last Published 12.17.2020
Effective Date: 01.01.2021 – Core Decompression for Avascular Necrosis – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Corneal Collagen Crosslinking – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Corneal Hysteresis and Intraocular Pressure Measurement – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Cosmetic and Reconstructive Procedures – Value & Balance Exchange Coverage Determination Guideline
Last Published 05.01.2021
Effective Date: 05.01.2021 – Crysvita® (Burosumab-Twza) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Cytogam® (Cytomegalovirus Immune Globulin) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Deep Brain and Cortical Stimulation – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Deferoxamine Mesylate – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Denosumab (Prolia® & Xgeva®) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 12.17.2020
Effective Date: 01.01.2021 – Discogenic Pain Treatment – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 –Drug Testing – Value & Balance Exchange Utilization Review Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Durable Medical Equipment, Orthotics, Medical Supplies and Repairs/Replacements – Value & Balance Exchange Coverage Determination Guideline
Last Published 05.01.2021
Effective Date: 05.01.2021 – Elective Inpatient Services – Value & Balance Exchange Utilization Review Guideline
Last Published 10.01.2020
Effective Date: 01.01.2021 – Electric Tumor Treatment Field Therapy – Value & Balance Exchange Medical Policy
Last Published 11.18.2020
Effective Date: 01.01.2021 – Electrical and Ultrasound Bone Growth Stimulators – Value & Balance Exchange Medical Policy
Last Published 11.17.2020
Effective Date: 01.01.2021 – Electrical Bioimpedance for Cardiac Output Measurement – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Electrical Stimulation and Electromagnetic Therapy for Wounds – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 07.01.2021 – Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Electroencephalographic (EEG) Monitoring and Video Recording – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Emergency Health Care Services and Urgent Care Center Services – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Enteral Nutrition – Value & Balance Exchange Coverage Determination Guideline
Last Published 04.01.2021
Effective Date: 04.01.2021 – Entyvio® (Vedolizumab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 06.01.2021 – Epidural Steroid Injections for Spinal Pain – Value & Balance Exchange Medical Policy
Last Published 02.01.2021
Effective Date: 02.01.2021 – Epiduroscopy, Epidural Lysis of Adhesions and Discography – Value & Balance Exchange Medical Policy
Last Published 12.17.2020
Effective Date: 01.01.2021 – Erythropoiesis-Stimulating Agents – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Ethyol® (Amifostine) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Evenity® (Romosozumab-Aqqg) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Evkeeza™ (evinacumab-dgnb) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Exondys 51® (Eteplirsen) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Facet Joint Injections for Spinal Pain – Value & Balance Exchange Medical Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Fecal Calprotectin Testing – Value & Balance Exchange Medical Policy
Last Published 03.01.2021
Effective Date: 03.01.2021 – Functional Endoscopic Sinus Surgery (FESS) – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – GamaSTAN®, GamaSTAN S/D® (Intramuscular Immune Globulin) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 03.01.2021
Effective Date: 03.01.2021 – Gamifant® (Emapalumab-Lzsg) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Gastrointestinal Motility Disorders, Diagnosis and Treatment – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea – Community Plan Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Gender Dysphoria Treatment – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Genetic Testing for Cardiac Disease – Value & Balance Exchange Medical Policy
Last Published 12.17.2020
Effective Date: 01.01.2021 – Genetic Testing for Hereditary Cancer – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Genetic Testing for Neuromuscular Disorders – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Genitourinary Pathogen Nucleic Acid Detection Panel Testing – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Givlaari® (Givosiran) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Glaucoma Surgical Treatments – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Gonadotropin Releasing Hormone Analogs – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Gynecomastia Treatment – Value & Balance Exchange Coverage Determination Guideline
Last Published 05.06.2021
Effective Date: 01.01.2021 – Habilitative Services and Outpatient Rehabilitation Therapy – Value & Balance Exchange Coverage Determination Guideline
Last Published 08.01.2021
Effective Date: 08.01.2021 – Hearing Aids and Devices Including Wearable, Bone Anchored and Semi-Implantable – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Helicobacter Pylori Serology Testing – Value & Balance Exchange Medical Policy
Last Published 02.01.2021
Effective Date: 01.01.2021 – Hepatitis Screening – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Hereditary Angioedema (HAE), Treatment and Prophylaxis – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Home Health Care, Skilled Care, and Custodial Care – Value & Balance Exchange Coverage Determination Guideline
Last Published 05.01.2021
Effective Date: 05.01.2021 – Home Hemodialysis – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Home Oxygen – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Home Traction Therapy – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Hospice Care – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Hysterectomy – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Ilaris® (Canakinumab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Ilumya™ (Tildrakizumab-Asmn) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Immune Globulin (IVIG and SCIG) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 07.01.2021 – Implanted Electrical Stimulator for Spinal Cord – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Infertility Diagnosis and Treatment – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Infertility Services – Value & Balance Exchange Coverage Determination Guideline
Last Published 05.01.2021
Effective Date: 05.01.2021 – Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 03.01.2021
Effective Date: 03.01.2021 – Inhaled Nitric Oxide for Infants – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Injectable Anticoagulants Arixtra® (Fondaparinux), Lovenox® (Enoxaparin), Fragmin® (Dalteparin) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Intensity-Modulated Radiation Therapy – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Intrauterine Fetal Surgery – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Kepivance® (Palifermin) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Ketalar® (Ketamine) and Spravato® (Esketamine) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Krystexxa® (Pegloticase) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Laser Interstitial Thermal Therapy – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Lemtrada (Alemtuzumab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 11.17.2020
Effective Date: 01.01.2021 – Light and Laser Therapy – Value & Balance Exchange Medical Policy
Last Published 11.17.2020
Effective Date: 01.01.2021 – Lithotripsy for Salivary Stones – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Long-Acting Injectable Antiretroviral Agents for HIV – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Lower Extremity Invasive Diagnostic and Endovascular Procedures – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Lung Volume Reduction Surgery – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Luxturna® (Voretigene Neparvovec-Rzyl) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Macular Degeneration Treatment Procedures – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Manipulation Under Anesthesia – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Manipulative Therapy – Value & Balance Exchange Medical Policy
Last Published 05.06.2021
Effective Date: 04.01.2021 – Manual Wheelchairs – Value & Balance Exchange Coverage Determination Guideline
Last Published 04.01.2021
Effective Date: 04.01.2021 – Maximum Dosage and Frequency – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 12.28.2020
Effective Date: 01.01.2021 – Mechanical Stretching Devices – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Medical Therapies for Enzyme Deficiencies – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Meniscus Implant and Allograft – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Mifeprex® (Mifepristone) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) and Achalasia – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Motorized Spinal Traction – Value & Balance Exchange Medical Policy
Last Published 05.06.2021
Effective Date: 01.01.2021 – Mozobil® (Plerixafor) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 03.01.2021
Effective Date: 03.01.2021 – Negative Pressure Wound Therapy – Value & Balance Exchange Medical Policy
Last Published 02.01.2021
Effective Date: 02.01.2021 – Nerve Graft to Restore Erectile Function During Radical Prostatectomy – Value & Balance Exchange Medical Policy
Last Published 03.01.2021
Effective Date: 03.01.2021 – Neurophysiologic Testing and Monitoring – Value & Balance Exchange Medical Policy
Last Published 02.01.2021
Effective Date: 02.01.2021 – Neuropsychological Testing Under the Medical Benefit – Value & Balance Exchange Medical Policy
Last Published 05.06.2021
Effective Date: 01.01.2021 – Nplate® (Romiplostim) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Nulojix® (Belatacept) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Observation Services – Value & Balance Exchange Utilization Review Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Obstructive Sleep Apnea Treatment – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Ocrevus® (Ocrelizumab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Off-Label/Unproven Specialty Drug Treatment – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 01.01.2021 – Office Based Procedures - Site of Service – Value & Balance Exchange Utilization Review Guideline
Last Published 05.01.2021
Effective Date: 05.01.2021 – Omnibus Codes – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Oncology Medication Clinical Coverage – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Onpattro® (Patisiran) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Orencia® (Abatacept) Injection for Intravenous Infusion – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Orthognathic (Jaw) Surgery – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Otoacoustic Emissions Testing – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Outpatient Surgical Procedures – Site of Service – Value & Balance Exchange Utilization Review Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Oxlumo™ (Lumasiran) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Panhematin® (Hemin) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 02.01.2021
Effective Date: 01.01.2021 – Panniculectomy and Body Contouring Procedures – Value & Balance Exchange Coverage Determination Guideline
Last Published 04.01.2021
Effective Date: 04.01.2021 – Parsabiv® (Etelcalcetide) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.06.2021
Effective Date: 04.01.2021 – Patient Lifts – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Pectus Deformity Repair – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Pediatric Gait Trainers, Standing Systems and Walkers – Value & Balance Exchange Coverage Determination Guideline
Last Published 10.01.2020
Effective 01.01.2021 – Pediatric Outpatient Intensive Feeding Programs – Value & Balance Exchange Utilization Review Guideline
Last Published 04.01.2021
Effective Date: 04.01.2021 – Percutaneous Patent Foramen Ovale (PFO) Closure – Value & Balance Exchange Medical Policy
Last Published 12.17.2020
Effective Date: 01.01.2021 – Percutaneous Vertebroplasty and Kyphoplasty – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Pharmacogenetic Testing – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Plagiocephaly and Craniosynostosis Treatment – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Pneumatic Compression Devices – Value & Balance Exchange Medical Policy
Last Published 05.06.2021
Effective Date: 04.01.2021 – Power Mobility Devices – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Preimplantation Genetic Testing – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses preventive care services.
Last Published 08.01.2021
Effective Date: 08.01.2021 – Private Duty Nursing (PDN) Services – Value & Balance Exchange Coverage Determination Guideline
Last Published 08.01.2021
Effective Date: 08.01.2021 – Prolotherapy and Platelet Rich Plasma Therapies – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Propranolol Treatment for Infantile Hemangiomas: Inpatient Protocol – Value & Balance Exchange Utilization Review Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Prostate Surgery – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs – Value & Balance Exchange Coverage Determination Guideline
Last Published 05.01.2021
Effective Date: 05.01.2021 – Proton Beam Radiation Therapy – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Pulmonary Arterial Hypertension Agents – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Radicava® (Edaravone) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Reblozyl® (Luspatercept-Aamt) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Referral to Out-of-Network Specialists – Value & Balance Exchange Utilization Review Guideline
Last Published 06.01.2021
Effective Date: 06.01.2021 – Repository Corticotropin Injection (Acthar® Gel) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Respiratory Interleukins (Cinqair®, Fasenra®, & Nucala®) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 01.01.2021 – Review at Launch for New to Market Medications – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
ffective Date: 07.01.2021 – Rhinoplasty and Other Nasal Surgeries – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – Rituximab (Riabni™, Rituxan®, Ruxience®, & Truxima®) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Sacroiliac Joint Injections – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Scenesse® (Afamelanotide) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 02.01.2021
Effective Date: 01.01.2021 – Self-Administered Medications (for North Carolina only) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 02.01.2021
Effective Date: 01.01.2021 – Self-Administered Medications – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 12.17.2020
Effective Date: 01.01.2021 – Sensory Integration Therapy and Auditory Integration Training – Value & Balance Exchange Medical Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Simponi Aria® (Golimumab) Injection for Intravenous Infusion – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.08.2021
Effective Date: 07.01.2021 – Simulect® (Basiliximab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Skin and Soft Tissue Substitutes – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Sodium Hyaluronate – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Somatostatin Analogs – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Speech Generating Devices – Value & Balance Exchange Coverage Determination Guideline
Last Published 10.01.2020
Effective Date: 01.01.2021 – Spinal Ultrasonography – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Spinraza® (Nusinersen) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Stelara® (Ustekinumab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Steroidal Intravitreal and Sinus Implants (Iluvien®, Ozurdex®, Retisert® and Propel®) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Subcutaneous Implantable Naltrexone Pellets – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Sublingual Immunotherapy – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 07.01.2021 – Surgery of the Ankle – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Surgery of the Elbow – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Surgery of the Foot – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Surgery of the Hand or Wrist – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Surgery of the Hip – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Surgery of the Knee – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Surgery of the Shoulder – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Surgical Treatment for Spine Pain – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Synagis® (Palivizumab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Temporomandibular Joint Disorders – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Tepezza® (Teprotumumab-Trbw) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Testosterone Replacement or Supplementation Therapy – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 05.06.2021
Effective Date: 04.01.2021 – Therapeutic Shoes and Inserts for Diabetics – Value & Balance Exchange Coverage Determination Guideline
Last Published 05.01.2021
Effective Date: 05.01.2021 – Thermography – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Thyrogen® (Thyrotropin Alfa) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Total Artificial Disc Replacement for the Spine – Value & Balance Exchange Medical Policy
Last Published 12.17.2020
Effective Date: 01.01.2021 – Total Artificial Heart and Ventricular Assist Devices – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Transcatheter Heart Valve Procedures – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Transcranial Magnetic Stimulation – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Transcutaneous Electrical Nerve/Joint Stimulators – Value & Balance Exchange Coverage Determination Guideline
Last Published 06.01.2021
Effective Date: 06.01.2021 – Transpupillary Thermotherapy – Value & Balance Exchange Medical Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Trogarzo® (Ibalizumab-Uiyk) – Value & Balance Exchange Medical Policy
Last Published 05.01.2021
Effective Date: 05.01.2021 – Tysabri® (Natalizumab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Umbilical Cord Blood Harvesting and Storage for Future Use – Value & Balance Exchange Medical Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Unicondylar Spacer Devices for Treatment of Pain or Disability – Value & Balance Exchange Medical Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Uplizna® (Inebilizumab-Cdon) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Vaccines – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Vagus and External Trigeminal Nerve Stimulation – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Vertebral Body Tethering for Scoliosis – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Vibativ ® (Telavancin) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Viltepso™ (Viltolarsen) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 12.17.2020
Effective Date: 01.01.2021 – Virtual Upper Gastrointestinal Endoscopy – Value & Balance Exchange Medical Policy
Last Published 12.28.2020
Effective Date: 01.01.2021 –Visual Information Processing Evaluation and Orthoptic and Vision Therapy – Value & Balance Exchange Medical Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Visudyne® (Verteporfin for Injection) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Vivitrol® (Naltrexone for Extended-Release Injectable Suspension) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Voraxaze® (Glucarpidase) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Vyepti™ (Eptinezumab-Jjmr) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Vyondys 53™ (Golodirsen) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 12.17.2020
Effective Date: 01.01.2021 – Warming Therapy and Ultrasound Therapy for Wounds – Value & Balance Exchange Medical Policy
Last Published 05.06.2021
Effective Date: 04.01.2021 – Wheelchair Options and Accessories – Value & Balance Exchange Coverage Determination Guideline
Last Published 05.06.2021
Effective Date: 04.01.2021 – Wheelchair Seating – Value & Balance Exchange Coverage Determination Guideline
Last Published 07.01.2021
Effective Date: 07.01.2021 – White Blood Cell Colony Stimulating Factors – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 02.01.2021
Effective Date: 02.01.2021 – Whole Exome and Whole Genome Sequencing – Value & Balance Exchange Medical Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Xiaflex® (Collagenase Clostridium Histolyticum) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 04.01.2021
Effective Date: 04.01.2021 – Xolair® (Omalizumab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Zilretta® (Triamcinolone Acetonide Extended Release) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 10.01.2020
Effective Date: 01.01.2021 – Zinplava™ (Bezlotoxumab) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 06.01.2021
Effective Date: 06.01.2021 – Zoledronic Acid – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 07.01.2021
Effective Date: 07.01.2021 – Zolgensma® (Onasemnogene Abeparvovec-Xioi) – Value & Balance Exchange Medical Benefit Drug Policy
Last Published 08.01.2021
Effective Date: 08.01.2021 – Zulresso™ (Brexanolone) – Value & Balance Exchange Medical Benefit Drug Policy
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.