The Medicare Advantage Policy Guidelines are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.
UnitedHealthcare has developed Medicare Advantage Policy Guidelines to assist us in administering health benefits. These Policy Guidelines are provided for informational purposes, and do not constitute medical advice. Treating physicians and healthcare 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.
Benefit coverage for health services is determined by the member specific benefit plan document* 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 the Medicare Advantage Policy Guidelines.
UnitedHealthcare follows Medicare coverage guidelines and regularly updates its Medicare Advantage Policy Guidelines to comply with changes in Centers for Medicare & Medicaid Services (CMS) policy. UnitedHealthcare encourages physicians and other healthcare professionals to keep current with any CMS policy changes and/or billing requirements by referring to the CMS or your local carrier website regularly. Physicians and other healthcare professionals can sign up for regular distributions for policy or regulatory changes directly from CMS and/or your local carrier. UnitedHealthcare's Medicare Advantage Policy Guidelines do not include notations regarding prior authorization requirements. View a list of services that are subject to notification/prior authorization requirements. Medicare Advantage Policy Guidelines may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations.
Medicare Advantage Policy 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. UnitedHealthcare may modify these Policy Guidelines at any time by publishing a new version of the policy on this website. The information presented in the Medicare Advantage Policy Guidelines is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis. Medicare Advantage Policy Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited.
You are responsible for submission of accurate claims. Medicare Advantage Policy Guidelines are intended to ensure that coverage decisions are made accurately based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Medicare Advantage Policy Guidelines use Current Procedural Terminology (CPT®**), CMS, or other coding guidelines. References to CPT® or other sources are for definitional purposes only and do not imply any right to reimbursement or guarantee claims payment.
*For more information on a specific member's benefit coverage, please call the customer service number on the back of the member ID card or refer to the Administrative Guide.
**CPT® is a registered trademark of the American Medical Association.
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The Policy Guidelines and corresponding update bulletins for UnitedHealthcare Medicare Advantage plans are listed below.
Open the sections below to view more information.
A monthly notice of recently approved and/or revised UnitedHealthcare Medicare Advantage Policy Guidelines is provided below for your review. We publish a new announcement on the first calendar day of every month.
The appearance of a health service (e.g., test, drug, device or procedure) in the Policy Guideline 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 Medicare Advantage Policy Guideline Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
Last Published 01.03.2023
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Policy Guidelines.
Last Published 02.01.2023
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Policy Guidelines.
Last Published 03.01.2023
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Policy Guidelines.
Last Published 03.01.2023
A listing of the Medicare Advantage Policy Guideline Update Bulletins for the past two rolling years.
Please Wait updating faceted results
Last Published 01.01.2023
This policy addresses abortion. Applicable Procedure Codes: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866.
Last Published 10.01.2022
This policy addresses acupuncture. Applicable Procedure Codes: 20560, 20561, 64999, 97810, 97811, 97813, 97814.
Last Published 11.01.2022
This policy addresses ambulatory electroencephalogram (EEG) monitoring to diagnose neurological conditions. Applicable Procedure Codes: 95700, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726.
Last Published 01.01.2023
This policy addresses the use of an anterior segment aqueous drainage device without extraocular reservoir. Applicable Procedure Codes: 0253T, 0449T, 0450T, 0474T, 0671T, 66183, 66189, 66991.
Last Published 09.01.2022
This policy addresses the use of Avastin® (bevacizumab) for cancer and ophthalmology indications. Applicable Procedure Codes: C9257, J7999, J9035, Q5107, Q5118.
Last Published 04.01.2022
This policy addresses bariatric surgery procedures for the treatment of morbid obesity and comorbid conditions. Applicable Procedure Codes: 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215.
Last Published 11.01.2022
This policy addresses the use of biomarkers in cardiovascular (CV) risk assessment. Applicable Procedure Codes: 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 86141.
Last Published 06.01.2022
This policy addresses blepharoplasty, blepharoptosis, and lid reconstruction. Applicable Procedure Codes: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924.
Last Published 03.01.2023
This policy addresses blood product molecular antigen typing. Applicable Procedure Codes: 0001U, 0084U, 0180U, 0181U, 0182U, 0183U, 184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0221U, 0222U, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112.
Last Published 03.01.2023
This policy addresses blood-derived products for chronic non-healing wounds. Applicable Procedure Codes: G0460, G0465.
Last Published 01.01.2023
This policy addresses bone mass measurement (BMM)/bone (mineral) density studies. Applicable Procedure Codes: 0508T, 0554T, 0555T, 0556T, 0557T, 0558T, 76977, 77078, 77080, 77081, 77085, 78350, 78351, G0130.
Last Published 04.01.2022
This policy addresses capsule endoscopy and wireless gastrointestinal motility monitoring systems. Applicable Procedure Codes: 0355T, 91110, 91111, 91112, 91113, 91299.
Last Published 09.01.2022
This policy addresses single and dual chamber permanent cardiac pacemakers. Applicable Procedure Codes: 33206, 33207, 33208.
Last Published 10.01.2022
This policy addresses cardiac rehabilitation programs and intensive cardiac rehabiliation programs for chronic heart failure. Applicable Procedure Codes: 93797, 93798 G0422, G0423.
Last Published 01.01.2023
This policy addresses Category III CPT codes used to track the utilization of emerging technologies, services, and procedures.
Last Published 07.01.2022
This policy addresses chiropractic manipulative treatment (CMT) services. Applicable Procedure Codes: 98940, 98941, 98942, 98943.
Last Published 02.01.2023
This policy addresses clinical diagnostic and preventive laboratory services and screenings.
Last Published 08.01.2022
This policy addresses cochlear implants and related services. Applicable Procedure Codes: 69930, L8614, L7510, L8619.
Last Published 07.01.2022
This policy addresses computerized tomography (CT) scanners, mobile CT equipment, multi-planar diagnostic imaging (MPDI), and computed tomographic angiography (CTA).
Last Published 01.01.2023
This policy addresses therapeutic continuous blood glucose monitoring (CGM) systems. Applicable Procedure Codes: 0446T, 0447T, 0448T, A4238, A4239, A9270, A9276, A9277, A9278, A9279, A9999, E1399, E2102, E2103, G0308, G0309, K0553, K0554.
Last Published 10.01.2022
This policy addresses computerized corneal topography. Applicable Procedure Code: 92025.
Last Published 02.01.2023
This policy addresses coronary fractional flow reserve using computed tomography (FFR-CT) for the evaluation of coronary artery disease (CAD), including the HeartFlow® FFRct technology. Applicable Procedure Codes: 0501T, 0502T, 0503T, and 0504T.
Last Published 10.01.2022
This policy addresses cosmetic, reconstructive, and plastic surgery services and procedures.
Last Published 02.01.2023
This policy addresses the use of cytogenetic studies for the diagnosis or treatment of genetic disorders in a fetus, failure of sexual development, chronic myelogenous leukemia, acute leukemias (lymphoid, myeloid, and unclassified), and myelodysplasia. Applicable Procedure Codes: 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291.
Last Published 10.01.2022
This policy addresses deep brain stimulation for essential tremor and Parkinson’s disease. Applicable Procedure Codes: 61885, 61886, 95961, 95962, 95970, 95971, 95983, 95984.
Last Published 01.01.2023
This policy addresses covered and non-covered dental services.
Last Published 09.01.2022
This policy addresses the use of Dimethyl Sulfoxide (DMSO) for the treatment of interstitial cystitis. Applicable Procedure Code: J1212.
Last Published 02.01.2023
This policy addresses the durable medical equipment (DME) list designed to facilitate UnitedHealthcare’s processing of DME claims.
Last Published 10.01.2022
This policy addresses electrotherapy for treatment of facial nerve paralysis (Bell's Palsy). Applicable Procedure Codes: 97032, G0283.
Last Published 06.01.2022
This policy addresses endothelial cell photography as a predictor of success of ocular surgery or certain other ocular procedures. Applicable Procedure Codes: 92285, 92286.
Last Published 09.01.2022
This policy addresses enteral and parenteral nutrition therapy and the related nutrients, equipment, and supplies.
Last Published 10.01.2022
This policy addresses the use of Erbitux® (cetuximab) for the treatment of colorectal cancer and head and neck cancer. Applicable Procedure Code: J9055.
Last Published 09.01.2022
This policy addresses the use of erythropoiesis stimulating agents (ESAs) and erythropoiesis stimulating agents (ESAs) in cancer and related neoplastic conditions for the treatment of anemia. Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, J0890, Q4081, Q5105, Q5106.
Last Published 06.01.2022
This policy addresses extracorporeal photopheresis. Applicable Procedure Code: 36522.
Last Published 12.01.2022
This policy addresses the use of Eylea® (aflibercept). Applicable Procedure Code: J0178.
Last Published 07.01.2022
This policy addresses facet joint interventions used in pain management. Applicable Procedure Codes: 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, 64999.
Last Published 10.01.2022
This policy addresses gender reassignment surgery for members with gender dysphoria.
Last Published 03.01.2023
This policy addresses genetic testing for hereditary cardiovascular disease. Applicable Procedure Codes: 0119U, 0237U, 81161, 81410, 81411, 81413, 81414, 81415, 81416, 81417, 81439, 81442.
Last Published 01.01.2023
This policy addresses genetic testing for hereditary cancer. Applicable Procedure Codes: 0101U, 0102U, 0103U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0158U, 0159U, 0160U, 0161U, 0162U, 0238U, 81162, 81163, 81164, 81165, 81166, 81167, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81307, 81308, 81317, 81318, 81319, 81321, 81322, 81323, 81351, 81352, 81353, 81432, 81433, 81435, 81436, 81437, 81438.
Last Published 10.01.2022
This policy addresses the use of Halaven® (eribulin mesylate). Applicable Procedure Code: J9179.
Last Published 11.01.2022
This policy addresses self-administered blood clotting factors and anti-inhibitor coagulant complex (AICC) for the treatment of hemophilia. Applicable Procedure Codes: J7170, J7175, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7198, J7199, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7212.
Last Published 03.01.2023
This policy addresses home blood glucose monitors. Applicable Procedure Codes: A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259, A9270, A9275, E0607, E0620, E2100, E2101.
Last Published 01.01.2023
This policy addresses home use of oxygen for patients with significant hypoxemia.
Last Published 09.01.2022
This policy addresses hospital beds for patient home use. Applicable Procedure Codes: E0193, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0271, E0272, E0273, E0274, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0301, E0302, E0303, E0304, E0305, E0310, E0315, E0316, E0328, E0329, E0910, E0911, E0912, E0940.
Last Published 02.01.2023
This policy addresses human tumor stem cell drug sensitivity assays. Applicable Procedure Codes: 0083U, 0248U, 0324U, 0325U 0564T, 81535, 81536, 84999, 86849, 89240.
Last Published 09.01.2022
This policy addresses hypoglossal nerve stimulation for the treatment of obstructive sleep apnea. Applicable Procedure Codes: 0466T, 0467T, 0468T, 64568, 64582, 64583, 64584.
Last Published 01.01.2023
This policy addresses implantable automatic/cardioverter defibrillators. Applicable Procedure Codes: 33202, 33203, 33215, 33216, 33217, 33218, 33220, 33223, 33224, 33225, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, G0448.
Last Published 02.01.2023
This policy addresses mechanical/hydraulic incontinence control devices, collagen implants, and the inFlow device for the treatment of incontinence. Applicable Procedure Codes: A4335, K1010, K1011, K1012, L8603, Q3031.
Last Published 03.01.2023
This policy addresses external and implantable infusion pumps.
Last Published 06.01.2022
This policy addresses intraocular photography. Applicable Procedure Codes: 92227, 92228, 92229, 92250.
Last Published 06.01.2022
This policy addresses intravenous immune globulin (IVIG). Applicable Procedure Codes: C0972, J1459, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599, Q2052.
Last Published 10.01.2022
This policy addresses the use of Jevtana® (cabazitaxel) for the treatment for hormone-refractory metastatic prostate cancer. Applicable Procedure Code: J9043.
Last Published 10.01.2022
This policy addresses prefabricated and custom fabricated knee orthoses.
Last Published 01.01.2023
This policy addresses use of the KX modifier to indicate fulfillment of coverage requirements.
Last Published 09.01.2022
This policy addresses leadless pacemakers. Applicable Procedure Codes: 33274, 33275.
Last Published 12.01.2022
This policy addresses long-term wearable electrocardiographic monitoring. Applicable Procedure Codes: 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272.
Last Published 09.01.2022
This policy addresses the use of Lucentis® (ranibizumab) for the treatment of macular degeneration and macular edema. Applicable Procedure Codes: C9093, J2778, Q5124.
Last Published 03.01.2023
This policy addresses lumbar artificial disc replacement (LADR) for treatment of degenerative or discogenic disc disease . Applicable Procedure Codes: 0163T, 0164T, 0165T, 22857, 22860, 22862, 22865.
Last Published 06.01.2022
This policy addresses magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA).
Last Published 04.01.2022
This policy addresses transoral incisionless fundoplication surgery (TIF) and endoluminal treatment for gastroesophageal reflux disease. Applicable Procedures Codes: 43210, 43257, 43284, 43285, 43289, 43499, 43999, 49999.
Last Published 03.01.2023
This policy addresses ambulatory mobility devices, including canes, walkers, and crutches. Applicable Procedure Codes: A4635, A4636, A4637, A9270, A9900, E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0153, E0154, E0155, E0156, E0157, E0158, E0159, E1399.
Last Published 02.01.2023
This policy addresses power operated vehicles and manual wheelchairs.
Last Published 01.01.2023
This policy addresses molecular diagnostic testing for infectious diseases, including deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) based analysis.
Last Published 01.01.2023
This policy addresses Human Leukocyte Antigen (HLA) typing to assess compatibility of recipients and potential donors as a part of solid organ and hematopoietic stem cell/ bone marrow pre-transplant testing. Applicable Procedure Codes: 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383.
Last Published 01.01.2023
This policy addresses molecular pathology and genetic testing when reported with unlisted codes. Applicable Procedure Codes: 81479, 81599, 84999.
Last Published 03.01.2023
This policy addresses molecular and genetic tests that have proven efficacy in the diagnosis or treatment of medical conditions.
Last Published 01.01.2023
This policy addresses the use of monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease. Applicable Procedure Code: J0172.
Last Published 11.01.2022
This policy addresses nebulizers for use when breathing is severely impaired.
Last Published 03.01.2023
This policy addresses negative pressure wound therapy pumps and supplies. Applicable Procedure Codes: A6550, A7000, A9272, E2402.
Last Published 10.01.2022
This policy addresses neuromuscular electrical stimulation (NMES) for the treatment of muscle atrophy and for use for walking in patients with spinal cord injury (SCI). Applicable Procedure Codes: E0744, E0745, E0764, E0770.
Last Published 08.01.2022
This policy addresses intraocular telescope (implantable miniature telescope [IMT]) for treatment related to end-stage age-related macular degeneration. Applicable Procedure Codes: 0308T, C1840.
Last Published 10.01.2022
This policy addresses electrical and ultrasonic osteogenic stimulators. Applicable Procedure Codes: E0747, E0748, E0749, E0760.
Last Published 09.01.2022
This policy addresses electrical and ultrasonic osteogenic stimulators. Applicable Procedure Codes: E0747, E0748, E0749, E0760.
Last Published 11.01.2022
This policy addresses partial ventriculectomy, also known as ventricular reduction, ventricular remodeling, or heart volume reduction surgery. Applicable Procedure Codes: 33548, 33999.
Last Published 11.01.2022
This policy addresses percutaneous coronary intervention (PCI). Applicable Procedure Codes: 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944, 92973, 92974, 92975, 92978, 92979, 93571, 93572, C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, C9608.
Last Published 07.01.2022
This policy addresses percutaneous left atrial appendage closure (LAAC). Applicable Procedure Code: 33340.
Last Published 11.15.2022
This policy addresses percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain. Applicable Procedure Code: 27279.
Last Published 08.01.2022
This policy addresses percutaneous transluminal angioplasty (PTA). Applicable Procedure Codes: 37215, 37799.
Last Published 09.01.2022
This policy addresses percutaneous insertion of an endovascular cardiac (ventricular) assist device. Applicable Procedure Codes: 33990, 33991, 33992, 33993, 33995, 33997.
Last Published 03.01.2023
This policy addresses pharmacogenomics testing (PGx). Applicable Procedure Codes: 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0117U, 0173U, 0175U, 0193U, 0286U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0345U, 81220, 81225, 81226, 81227, 81230, 81231, 81232, 81247, 81283, 81306, 81328, 81335, 81346, 81350, 81355, 81418.
Last Published 07.01.2022
This policy addresses the use of ocular photodynamic therapy (OPT) for the treatment of ophthalmologic diseases. Applicable Procedure Codes: 67221, 67225, J3396.
Last Published 09.01.2022
This policy addresses platelet rich plasma injections/applications for the treatment of musculoskeletal injuries or joint conditions. Applicable Procedure Codes: M0076, P9020.
Last Published 09.01.2022
This policy addresses pneumatic devices for the treatment of lymphedema and for chronic venous insufficiency with venous stasis ulcers. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Last Published 11.01.2022
This policy addresses podiatry services pertaining to routine foot care. Applicable Procedure Codes: 11055, 11056, 11057, 11719, 11720, 11721, G0127.
Last Published 03.01.2023
This policy addresses porcine (pig) skin dressings and gradient pressure dressings. Applicable Procedure Codes: A2001, A2004, A2008, A2010, A2013, A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513, A6530, A6531, A6532, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, A6544, A6545, A6549, Q4102, Q4103, Q4118, Q4124, Q4130, Q4135, Q4136, Q4142, Q4166, Q4175, Q4195, Q4196, Q4197, Q4203.
Last Published 10.01.2022
This policy addresses positron emission tomography (PET) scans.
Last Published 10.01.2022
This policy addresses computerized dynamic posturography (CDP) for the treatment of neurologic disease and inherited disorders, peripheral vestibular disorders, and disequilibrium in the aging/elderly. Applicable Procedure Code: 92548.
Last Published 09.01.2022
This policy addresses the use of Group 1, Group 2, and Group 3 pressure reducing support surfaces for the care of pressure sores, also known as pressure ulcers. Applicable Procedure Codes: A4640, A9270, E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0194, E0196, E0197, E0198, E0199, E0277, E0371, E0372, E0373, E1399.
Last Published 12.01.2022
This policy addresses prostate rectal spacers for use in men receiving radiation therapy for prostate cancer. Applicable Procedure Code: 55874.
Last Published 09.01.2022
This policy addresses routine costs of qualifying clinical trials.
Last Published 02.01.2023
This policy addresses the use of sacral nerve stimulation for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Applicable Procedure Codes: 64561, 64581.
Last Published 09.01.2022
This policy addresses scalp hypothermia during chemotherapy to prevent hair loss. Applicable Procedure Codes: 97010, E1399.
Last Published 11.01.2022
This policy addresses drugs or biologicals that are usually self-administered by the patient.
Last Published 01.01.2023
This policy addresses sleep testing for obstructive sleep apnea (OSA). Applicable Procedure Codes: 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
Last Published 11.01.2022
This policy addresses the implantation of spinal cord stimulators (SCS) for the relief of chronic intractable pain. Applicable Procedure Codes: 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688.
Last Published 02.01.2023
This policy addresses the use of Spravato® (Esketamine) for the treatment of treatment-resistant depression (TRD) in adults. Applicable Procedure Codes: G2082, G2083, J3490.
Last Published 11.01.2022
This policy addresses stem cell transplantation, including allogeneic hematopoietic stem cell transplantation (HSCT) and autologous stem cell transplantation (AuSCT). Applicable Procedure Codes: 38240, 38241.
Last Published 03.01.2023
This policy addresses sterilization. Applicable Procedure Codes: 55250, 58600, 58605, 58611, 58615, 58670, 58671.
Last Published 07.01.2022
This policy addresses injectable testosterone pellets (Testopel®). Applicable Procedure Codes: 11980, J3490.
Last Published 11.01.2022
This policy addresses the use of percutaneous thermal intradiscal procedures (TIPs) for the treatment of low back pain. Applicable Procedure Codes: 22526, 22527, 22899, 64999.
Last Published 01.01.2023
This policy addresses Tier 2 molecular pathology procedures, which are procedures not identified by Tier 1 molecular pathology procedures or other CPT codes. Applicable Procedure Codes: 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408.
Last Published 10.01.2022
This policy addresses transcatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation (TAVI), for the treatment of aortic stenosis. Applicable Procedure Codes: 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369.
Last Published 03.01.2022
This policy addresses transcatheter mitral valve repair (TMVR) for the treatment of mitral regurgitation. Applicable Procedure Codes: 0345T, 33418, 33419.
Last Published 10.01.2022
This policy addresses transcutaneous electrical nerve stimulation (TENS) for the relief of acute post-operative pain, chronic pain other than low back pain and chronic low back pain. Applicable Procedure Codes: A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731.
Last Published 12.01.2022
This policy addresses transportation services, including emergency ambulance services (ground), non-emergency (scheduled) ambulance service (ground), emergency air ambulance transportation, and ambulance service to a physician's office.
Last Published 09.01.2022
This policy addresses tumor treatment field therapy. Applicable Procedure Codes: A4555, E0766.
Last Published 11.01.2022
This policy addresses ultrasound diagnostic procedures utilizing low energy sound waves.
Last Published 06.01.2022
This policy addresses urological supplies related to urinary catheters and external urinary collection devices.
Last Published 12.01.2022
This policy addresses vaccinations/immunizations.
Last Published 02.01.2023
This policy addresses vagus nerve stimulation (VNS) for the treatment of refractory epilepsy and partial onset seizures. Applicable Procedure Codes: 61885, 61886, 64568, 64569, 64570, 95976, 95977.
Last Published 09.01.2022
This policy addresses the use of a ventricular assist device (VAD) to assist or augment the ability of a damaged or weakened native heart to pump blood. Applicable Procedure Codes: 33979, 33980, 33982, 33983.
Last Published 05.01.2022
This policy addresses testing for vitamin D deficiency. Applicable Procedure Codes: 82306, 82652.
Last Published 08.01.2022
This policy addresses a surgical or other invasive procedure that is performed on the wrong patient/body part or is the incorrect procedure for the patient’s condition.
Last Published 01.01.2023
This policy addresses the use of Xgeva®, Prolia® (denosumab) for the treatment of osteoporosis in postmenopausal women with a high risk of bone fractures. Applicable Procedure Code: J0897.
Last Published 03.01.2022
This policy addresses the use of Xofigo® (radium Ra 223 dichloride) injection for the treatment of castration-resistant prostate cancer (CRPC), symptomatic bone metastases, and no known visceral metastatic disease. Applicable Procedure Codes: 79101, A9606.
Last Published 09.01.2022
This policy addresses the use of zoledronic acid (Zometa® & Reclast®). Applicable Procedure Code: J3489.
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s health ID card.