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 07.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Policy Guidelines.
Last Published 09.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Policy Guidelines.
Last Published 09.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Policy Guidelines.
Last Published 09.01.2021
Last Published 07.01.2021
This policy addresses abortion. Applicable Procedure Codes: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866.
Last Published 06.01.2021
This policy addresses acupuncture. Applicable Procedure Codes: 20560, 20561, 64999, 97810, 97811, 97813, 97814.
Last Published 04.01.2021
This policy addresses acupuncture for treatment of chronic low back pain (cLBP). Applicable Procedure Codes: 20560, 20561, 97810, 97811, 97813, 97814.
Last Published 06.01.2021
This policy addresses acupuncture for fibromyalgia. Applicable Procedure Codes: 20560, 20561, 64999, 97810, 97811, 97813, 97814.
Last Published 06.01.2021
This policy addresses acupuncture for osteoarthritis. Applicable Procedure Codes: 20560, 20561, 64999, 97810, 97811, 97813, 97814.
Last Published 08.01.2021
This policy addresses adult liver transplantation. Applicable Procedure Codes: 47135, 47399.
Last Published 07.01.2021
This policy addresses home use of the air-fluidized bed for treatment of pressure sores. Applicable Procedure Code: E0194.
Last Published 08.01.2021
This policy addresses ambulatory blood pressure monitoring (ABPM). Applicable Procedure Code: 93784.
Last Published 04.01.2021
This policy addresses ambulatory EEG monitoring. Applicable Procedure Codes: 95700, 95705, 95708, 95717, 95719, 95721, 95950, 95953.
Last Published 09.01.2021
This policy addresses the use of an anterior segment aqueous drainage device without extraocular reservoir. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 66183.
Last Published 04.01.2021
This policy addresses anti-inhibitor coagulant complex (AICC) used to treat hemophilia in patients with factor VIII inhibitor antibodies. Applicable Procedure Code: J7198.
Last Published 04.01.2021
This policy addresses antigens administered sublingually. Applicable Procedure Codes: 95199.
Last Published 04.01.2021
This policy addresses apheresis (also known as pheresis or therapeutic pheresis). Applicable Procedure Codes: 36511, 36512, 36513, 36514.
Last Published 04.01.2021
This policy addresses the use of an oral antiemetic three-drug combination used for chemotherapy-induced nausea and vomiting (CINV), including aprepitant (Emend®), a 5HT3 antagonist, and dexamethasone. Applicable Procedure Codes: J8501, J8540, J8655, J8670, Q0162, Q0166, Q0180, Q0181.
Last Published 06.01.2021
This policy addresses arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee. Applicable Procedure Codes: 29877, 29999.
Last Published 09.01.2021
This policy addresses artificial hearts and related services and devices. Applicable Procedure Codes: 33927, 33928, 33929.
Last Published 08.01.2021
This policy addresses electrical nerve stimulation is an accepted modality for assessing a patient's suitability for ongoing treatment with a transcutaneous or an implanted nerve stimulator.
Last Published 04.01.2021
This policy addresses autologous cellular immunotherapy treatment using PROVENGE® (sipuleucel-T). Applicable Procedure Code: Q2043.
Last Published 08.01.2021
This policy addresses the use of Avastin® (bevacizumab) for cancer and ophthalmology indications. Applicable Procedure Codes: C9257, J7999, J9035, Q5107, Q5118.
Last Published 04.01.2021
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 06.01.2021
This policy addresses the use of the Benson-Henry Institute Cardiac Wellness Program as an intensive cardiac rehabilitation (ICR) program.
Last Published 04.01.2021
This policy addresses biofeedback therapy. Applicable Procedure Codes: 90875, 90876, 90901, 90912, 90913.
Last Published 04.01.2021
This policy addresses biofeedback therapy for the treatment of urinary incontinence. Applicable Procedure Codes: 90901, 90912, 90913.
Last Published 04.01.2021
This policy addresses the use of biomarkers in cardiovascular (CV) risk assessment. Applicable Procedure Codes: 81439, 81479, 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 86141.
Last Published 04.01.2021
This policy addresses bladder stimulators/pacemakers, including spinal cord electrical stimulators, rectal electrical stimulators, and bladder wall stimulators. Applicable Procedure Codes: L8499, L8699.
Last Published 06.01.2021
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, 67961.
Last Published 04.01.2021
This policy addresses blood brain barrier osmotic disruption for treatment of brain tumor. Applicable Procedure Codes: 64999, 96549.
Last Published 09.01.2021
This policy addresses blood platelet transfusions. Applicable Procedure Codes: P9019, P9020, P9031, P9032, P9033, P9034, P9035, P9036, P9037, P9052, P9053, P9055, P9073, P9100.
Last Published 04.01.2021
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, 81403.
Last Published 09.01.2021
This policy addresses blood transfusions. Applicable Procedure Codes: 86890, 86891, 86985, P9010, P9011, P9012, P9016, P9017, P9021, P9022, P9023, P9038, P9039, P9040, P9043, P9044, P9048, P9051, P9054, P9056, P9057, P9058, P9059, P9060, P9070, P9071, P9099.
Last Published 04.01.2021
This policy addresses blood-derived products for chronic non-healing wounds. Applicable Procedure Code: G0460.
Last Published 04.01.2021
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 05.01.2021
This policy addresses BRCA1 and BRCA2 genetic testing for hereditary cancers. Applicable Procedure Codes: 0102U, 0103U, 0129U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81432, 81433.
Last Published 09.01.2021
This policy addresses reconstruction of the affected and the contralateral unaffected breast following mastectomy . Applicable Procedure Codes: 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396.
Last Published 04.01.2021
This policy addresses the use of Camptosar® (irinotecan hydrochloride) for the treatment of metastatic carcinoma of the colon or rectum. Applicable Procedure Code: J9206.
Last Published 05.15.2021
This policy addresses capsule endoscopy and wireless gastrointestinal motility monitoring systems. Applicable Procedure Codes: 0355T, 91110, 91111, 91112, 91299.
Last Published 04.01.2021
This policy addresses the use of thoracic electrical bioimpedance (TEB) devices to monitor cardiac output. Applicable Procedure Code: 93701.
Last Published 07.01.2021
This policy addresses follow-up and evaluation of implanted cardiac pacemakers. Applicable Procedure Codes: 93279, 93280, 93281, 93286, 93288, 93294, 93296, 93724.
Last Published 05.01.2021
This policy addresses single and dual chamber permanent cardiac pacemakers. Applicable Procedure Codes: 33206, 33207, 33208.
Last Published 06.01.2021
This policy addresses cardiac rehabilitation programs for chronic heart failure. Applicable Procedure Codes: 93797, 93798.
Last Published 04.01.2021
This policy addresses carotid body resection and denervation of a carotid sinus. Applicable Procedure Codes: 60600, 60605.
Last Published 09.01.2021
This policy addresses Category III CPT codes used to track the utilization of emerging technologies, services, and procedures
Last Published 08.01.2021
This policy addresses cavernous nerves electrical stimulation with penile plethysmography. Applicable Procedure Codes: 54240, 55899.
Last Published 04.01.2021
This policy addresses challenge ingestion food testing used in the diagnosis of food allergies. Applicable Procedure Codes: 95076, 95079.
Last Published 07.01.2021
This policy addresses chimeric antigen receptor (CAR) T-cell immunotherapy for the treatment of cancer. Applicable Procedure Codes: 0537T, 0538T, 0539T, 0540T, C9073, C9399, Q2041, Q2042, Q2053.
Last Published 04.01.2021
This policy addresses chiropractic manipulative treatment (CMT) services. Applicable Procedure Codes: 98940, 98941, 98942, 98943.
Last Published 08.01.2021
This policy addresses clinical diagnostic and preventive laboratory services and screenings.
Last Published 04.01.2021
This policy addresses use of a closed-loop blood glucose control device (CBGCD) for the treatment of insulin dependent diabetes mellitus (Type I).
Last Published 08.01.2021
This policy addresses cochlear implants and related services. Applicable Procedure Codes: 69930, L8614, L7510, L8619.
Last Published 05.01.2021
This policy addresses cochleostomy with neurovascular transplant for treatment of Meniere's disease/syndrome. Applicable Procedure Code: 69949.
Last Published 04.01.2021
This policy addresses collagen meniscus implant. Applicable Procedure Code: G0428.
Last Published 04.01.2021
This policy addresses colonic irrigation. Applicable Procedure Code: 45399.
Last Published 04.01.2021
This policy addresses the use of filgrastim (Neupogen®), filgrastim-sndz (Zarxio®), filgrastim-aafi (Nivestym™), pegfilgrastim (Neulasta®), pegfilgrastim-jmdb (Fulphila™), tbo-filgrastim (Granix®), and sargramostim (Leukine®). Applicable Procedure Codes: C9058, J1442, J1447, J2505, J2820, Q5101, Q5108, Q5110, Q5111, Q5120.
Last Published 08.01.2021
This policy addresses colorectal cancer screening services/tests, including fecal occult blood tests, flexible sigmoidoscopy, colonoscopy, barium enema, multitarget stool DNA tests, and computed tomographic colonography. Applicable Procedure Codes: 00811, 00812, 74263, 81528, 82270, G0104, G0105, G0106, G0120, G0121, G0122, G0327, G0328.
Last Published 06.01.2021
This policy addresses computerized tomography (CT) scanners, mobile CT equipment, multi-planar diagnostic imaging (MPDI), and computed tomographic angiography (CTA).
Last Published 06.01.2021
This policy addresses computer enhanced perimetry used to assess visual fields in patients with glaucoma or other neuropathologic defects. Applicable Procedure Codes: 92081, 92082, 92083.
Last Published 09.01.2021
This policy addresses continuous positive airway pressure (CPAP) and other respiratory assist devices (RAD) therapy for obstructive sleep apnea (OSA). Applicable Procedure Codes: A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0470, E0471, E0561, E0562, E0601.
Last Published 04.01.2021
This policy addresses computerized corneal topography. Applicable Procedure Code: 92025.
Last Published 04.01.2021
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 09.01.2021
This policy addresses cosmetic, reconstructive, and plastic surgery services and procedures.
Last Published 07.01.2021
This policy addresses tobacco cessation counseling. Applicable Procedure Codes: 99406, 99407.
Last Published 04.01.2021
This policy addresses drugs and biologicals for label and off-label uses.
Last Published 08.01.2021
This policy addresses cryosurgery of the prostate gland, also known as cryosurgical ablation of the prostate (CSAP). Applicable Procedure Code: 55873.
Last Published 08.01.2021
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 06.01.2021
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 08.01.2021
This policy addresses delivery of intensity modulated radiation therapy (IMRT), stereotactic radiosurgery (SRS), and stereotactic body radiation therapy (SBRT). Applicable Procedure Codes: 77301, 77338, 77371, 77372, 77373, 77385, 77386, 77432, 77435, G0339, G0340, G6015, G6016.
Last Published 08.01.2021
This policy addresses oral or dental examination performed prior to renal transplant surgery.
Last Published 04.01.2021
This policy addresses covered and non-covered dental services.
Last Published 04.01.2021
This policy addresses dermal injections for the treatment of facial lipodystrophy syndrome (LDS). Applicable Procedure Codes: G0429, Q2026, Q2028.
Last Published 04.01.2021
This policy addresses diabetes self-management training (DSMT) services. Applicable Procedure Codes: G0108, G0109.
Last Published 04.01.2021
This policy addresses diagnostic pap smears and related services. Applicable Procedure Codes: 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175.
Last Published 04.01.2021
This policy addresses diathermy treatment. Applicable Procedure Code: 97024.
Last Published 04.01.2021
This policy addresses the use of Dimethyl Sulfoxide (DMSO) for the treatment of interstitial cystitis. Applicable Procedure Code: J1212.
Last Published 04.01.2021
This policy addresses displacement cardiography, including cardiokymography and photokymography, for evaluating coronary artery disease. Applicable Procedure Codes: 93799, Q0035.
Last Published 09.01.2021
This policy addresses the durable medical equipment (DME) list designed to facilitate UnitedHealthcare’s processing of DME claims.
Last Published 04.01.2021
This policy addresses electrical continence aids. Applicable Procedure Codes: L8499, L8699.
Last Published 04.01.2021
This policy addresses electrical nerve stimulators for the treatment of chronic intractable pain, including implanted peripheral nerve stimulators and central nervous system stimulators.
Last Published 04.01.2021
This policy addresses electrical stimulation (ES) and electromagnetic therapy for the treatment of wounds. Applicable Procedure Codes: G0281, G0282, G0295, G0329.
Last Published 04.01.2021
This policy addresses electrocardiographic (EKG) services. Applicable Procedure Codes: 93000, 93005, 93010, 93040, 93041, 93042.
Last Published 04.01.2021
This policy addresses electrotherapy for treatment of facial nerve paralysis (Bell's Palsy). Applicable Procedure Codes: 97032, G0283.
Last Published 04.01.2021
This policy addresses the use of Eloxatin® (oxaliplatin) for the treatment of advanced carcinoma of the colon or rectum. Applicable Procedure Code: J9263.
Last Published 06.01.2021
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 05.01.2021
This policy addresses enteral and parenteral nutrition therapy and the related nutrients, equipment, and supplies.
Last Published 04.01.2021
This policy addresses the use of Erbitux® (cetuximab) for the treatment of colorectal cancer, head and neck cancer, and non-small cell lung cancer (NSCLC). Applicable Procedure Code: J9055.
Last Published 04.01.2021
This policy addresses erythropoiesis stimulating agents (ESAs) in cancer and related neoplastic conditions. Applicable Procedure Codes: J0881, J0885, Q5106.
Last Published 04.01.2021
This policy addresses the use of erythropoietin stimulating agents (ESAs) for the treatment of anemia. Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, J0890, Q4081, Q5105, Q5106.
Last Published 04.01.2021
This policy addresses evoked response tests. Applicable Procedure Codes: 92585, 92586, 92650, 92651, 92652, 92653, 95925, 95926, 95927, 95928, 95929, 95930, 95938, 95939.
Last Published 07.01.2021
This policy addresses external counterpulsation (ECP) therapy for the treatment of severe angina. Applicable Procedure Code: G0166.
Last Published 05.01.2021
This policy addresses extracorporeal photopheresis. Applicable Procedure Code: 36522.
Last Published 06.01.2021
This policy addresses extracranial-intracranial (EC-IC) arterial bypass surgery for the treatment for ischemic cerebrovascular disease of the carotid or middle cerebral arteries. Applicable Procedure Codes: 61711, 64999.
Last Published 06.01.2021
This policy addresses the use of Eylea® (aflibercept) Applicable Procedure Codes: 67028, J0178.
Last Published 07.01.2021
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 04.01.2021
This policy addresses sublingual intracutaneous and subcutaneous provocative and neutralization testing and neutralization therapy (Rinkel Test) for food allergies. Applicable Procedure Code: 95199.
Last Published 05.01.2021
This policy addresses gastrophotography for the diagnosis and treatment of gastrointestinal disorders. Applicable Procedure Code: 44799.
Last Published 09.01.2021
This policy addresses gender reassignment surgery for members with gender dysphoria.
Last Published 05.01.2021
This policy addresses genetic testing guidelines for Lynch syndrome. Applicable Procedure Codes: 0101U, 0130U, 0158U, 0159U, 0160U, 0161U, 0162U, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81435, 81436, 88341, 88342.
Last Published 04.01.2021
This policy addresses the use of Halaven® (eribulin mesylate). Applicable Procedure Code: J9179.
Last Published 09.01.2021
This policy addresses heart transplants. Applicable Procedure Codes: 33933, 33935, 33940, 33944, 33945.
Last Published 04.01.2021
This policy addresses self-administered blood clotting factors for the treatment of hemophilia. Applicable Procedure Codes: C9141, 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 05.01.2021
This policy addresses histocompatibility testing prior to transplants and transfusions, and for ankylosing spondylitis. Applicable Procedure Codes: 86812, 86813, 86816, 86817, 86821, 86825, 86826.
Last Published 09.01.2021
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 04.01.2021
This policy addresses home health nurses' visits to patients requiring heparin injection. Applicable Procedure Codes: 99601, 99602, J1644, T1502.
Last Published 05.01.2021
This policy addresses home oxygen use to treat cluster headache (CH). Applicable Procedure Codes: E0424, E0441.
Last Published 08.01.2021
This policy addresses home prothrombin time/international normalized ratio (PT/INR) monitoring for anticoagulation treatment. Applicable Procedure Codes: G0248, G0249, G0250.
Last Published 04.01.2021
This policy addresses home use of oxygen for patients with significant hypoxemia.
Last Published 04.01.2021
This policy addresses home use of oxygen in clinical trials approved by the Centers for Medicare & Medicaid Services (CMS) and sponsored by the National Heart, Lung & Blood Institute (NHLBI).
Last Published 07.01.2021
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 04.01.2021
This policy addresses human tumor stem cell drug sensitivity assays. Applicable Procedure Codes: 0083U, 0564T, 81535, 81536, 84999, 86849, 89240.
Last Published 06.01.2021
This policy addresses hydrophilic contact lens for corneal bandage. Applicable Procedure Codes: 92071, 92072, 92310.
Last Published 06.01.2021
This policy addresses hydrophilic contact lenses. Applicable Procedure Codes: V2520, V2521, V2522, V2523, V2524.
Last Published 04.01.2021
This policy addresses hyperbaric oxygen therapy. Applicable Procedure Codes: 97799, 99183, 99199, A4575, E0446, G0277.
Last Published 04.01.2021
This policy addresses hyperthermia for treatment of cancer. Applicable Procedure Codes: 77600, 77605, 77610, 77615, 77620.
Last Published 05.01.2021
This policy addresses hypoglossal nerve stimulation for the treatment of obstructive sleep apnea. Applicable Procedure Codes: 0466T, 0467T, 0468T, 64568.
Last Published 06.01.2021
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 04.01.2021
This policy addresses mechanical/hydraulic incontinence control devices, collagen implants, and the inFlow device for the treatment of incontinence. Applicable Procedure Codes: K1010, K1011, K1012, L8603, Q3031.
Last Published 06.01.2021
This policy addresses use of the INDEPENDENCE iBOT 4000 Mobility System. Applicable Procedure Code: K0898.
Last Published 04.01.2021
This policy addresses infrared therapy devices and any related accessories. Applicable Procedure Codes: 97026, A4639, E0221.
Last Published 04.01.2021
This policy addresses external and implantable infusion pumps.
Last Published 04.01.2021
This policy addresses insulin syringes and needles. Applicable Procedure Codes: A4206, A4210, A4211.
Last Published 09.01.2021
This policy addresses intensive behavioral therapy for cardiovascular disease (CVD). Applicable Procedure Code: G0446.
Last Published 04.01.2021
This policy addresses intensive behavioral therapy for obesity. Applicable Procedure Codes: G0447, G0473.
Last Published 06.01.2021
This policy addresses intensive cardiac rehabilitation (ICR) programs. Applicable Procedure Codes: G0422, G0423.
Last Published 08.01.2021
This policy addresses multi-visceral and intestinal transplantation for the treatment of irreversible intestinal failure. Applicable Procedure Codes: 44132, 44133, 44135, 44136.
Last Published 09.01.2021
This policy addresses intraocular lenses (pseudophakos) and related implantation services. Applicable Procedure Codes: C1780, V2630, V2631, V2632, V2787, V2788.
Last Published 06.01.2021
This policy addresses intraocular photography. Applicable Procedure Codes: 92227, 92228, 92250.
Last Published 09.01.2021
This policy addresses intrapulmonary percussive ventilator (IPV). Applicable Procedure Code: E0481
Last Published 04.01.2021
This policy addresses intravenous histamine therapy. Applicable Procedure Codes: 95199, 96379.
Last Published 07.01.2021
This policy addresses intravenous immune globulin (IVIG). Applicable Procedure Codes: C0972, J1459, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599, Q2052.
Last Published 06.01.2021
This policy addresses intravenous immune globulin (IVIg) for the treatment of mucocutaneous blistering diseases. Applicable Procedure Codes: J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599.
Last Published 04.01.2021
This policy addresses intravenous iron therapy for treatment of iron deficiency anemia. Applicable Procedure Codes: J1756, J2916.
Last Published 08.01.2021
This policy addresses islet cell transplantation/pancreatic tissue transplantation in context of a clinical trial. Applicable Procedure Codes: G0341, G0342, G0343.
Last Published 04.01.2021
This policy addresses the use of Jevtana® (cabazitaxel) for the treatment for hormone-refractory metastatic prostate cancer. Applicable Procedure Code: J9043.
Last Published 04.01.2021
This policy addresses kidney disease education (KDE) interventions. Applicable Procedure Codes: G0420, G0421.
Last Published 07.01.2021
This policy addresses prefabricated and custom fabricated knee orthoses.
Last Published 07.01.2021
This policy addresses use of the KX modifier to indicate fulfillment of coverage requirements.
Last Published 04.01.2021
This policy addresses the use of levodopa (L-Dopa) for the treatment of Parkinson's disease. Applicable Procedure Codes: J3490, J3590, J7340.
Last Published 04.01.2021
This policy addresses the use of laser procedures for many medical indications.
Last Published 09.01.2021
This policy addresses leadless pacemakers. Applicable Procedure Codes: 33274, 33275.
Last Published 04.01.2021
This policy addresses attended electroencephalogram (EEG) monitoring to diagnose neurological conditions. Applicable Procedure Codes: 95706, 95707, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95723, 95724, 95725, 95726, 95951, 95956.
Last Published 04.01.2021
This policy addresses long-term wearable electrocardiographic monitoring. Applicable Procedure Codes: 0295T, 0296T, 0297T, 0298T, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272.
Last Published 04.01.2021
This policy addresses low frequency, non-contact, non-thermal ultrasound. Applicable Procedure Code: 97610.
Last Published 07.01.2021
This policy addresses lower limb prostheses, including feet, ankles, knees, hips, and sockets.
Last Published 07.01.2021
This policy addresses the use of Lucentis® (ranibizumab) for the treatment of macular degeneration and macular edema. Applicable Procedure Code: J2778.
Last Published 04.01.2021
This policy addresses lumbar artificial disc replacement (LADR) for treatment of degenerative or discogenic disc disease . Applicable Procedure Codes: 0163T, 0164T, 0165T, 22857, 22862, 22865.
Last Published 04.01.2021
This policy addresses lung cancer screening with low dose computed tomography (LDCT). Applicable Procedure Codes: 71271, G0296, G0297.
Last Published 08.01.2021
This policy addresses lung volume reduction surgery (LVRS)/reduction pneumoplasty for treating severe emphysema. Applicable Procedure Codes: 32491, G0302, G0303, G0304, G0305.
Last Published 04.01.2021
This policy addresses lymphocyte mitogen response assay used to assess lymphocytic function in diagnosed immunodeficiency diseases and to monitor immunotherapy. Applicable Procedure Codes: 86352, 86353.
Last Published 05.01.2021
This policy addresses the use of magnetic resonance image guided high intensity focused ultrasound (MRgFUS) treatment of idiopathic essential tremor (ET). Applicable Procedure Code: 0398T.
Last Published 06.01.2021
This policy addresses magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA).
Last Published 04.01.2021
This policy addresses screening and diagnostic mammograms. Applicable Procedure Codes: 77063, 77065, 77066, 77067, G0279.
Last Published 08.01.2021
This policy addresses manipulations other than chiropractic and osteopathic, including manipulation of the rib cage and head. Applicable Procedure Codes: 94667, 94668.
Last Published 04.01.2021
This policy addresses medical nutrition therapy (MNT) services. Applicable Procedure Codes: 97802, 97803, 97804, G0270, G0271.
Last Published 04.01.2021
This policy addresses microvolt T-wave alternans (MTWA) testing for patients at risk for sudden cardiac death (SCD) from ventricular arrhythmias. Applicable Procedure Code: 93025.
Last Published 07.01.2021
This policy addresses transoral incisionless fundoplication surgery (TIF) and endoluminal treatment for gastroesophageal reflux disease. Applicable Procedures Codes: 43210, 43284, 43285, 43289, 43499, 49999.
Last Published 04.01.2021
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 05.01.2021
This policy addresses power operated vehicles and manual wheelchairs.
Last Published 09.01.2021
This policy addresses molecular diagnostic testing for infectious diseases, including deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) based analysis.
Last Published 04.01.2021
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 09.01.2021
This policy addresses molecular pathology and genetic testing when reported with unlisted codes. Applicable Procedure Codes: 81479, 81599, 84999, 85999, 86849.
Last Published 06.01.2021
This policy addresses molecular and genetic tests that have proven efficacy in the diagnosis or treatment of medical conditions.
Last Published 05.01.2021
This policy addresses multiple-seizure electroconvulsive therapy (MECT). Applicable Procedure Code: 90899.
Last Published 04.01.2021
This policy addresses nebulizers for use when breathing is severely impaired.
Last Published 04.01.2021
This policy addresses negative pressure wound therapy pumps and supplies. Applicable Procedure Codes: A6550, A7000, A9272, E2402.
Last Published 04.01.2021
This policy addresses the use of nesiritide (Natrecor®) for the intravenous treatment of patients with acutely decompensated congestive heart failure (CHF). Applicable Procedure Code: J2325.
Last Published 08.01.2021
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.
Last Published 04.01.2021
This policy addresses noncontact normothermic wound therapy (NNWT). Applicable Procedure Codes: A6000, E0231, E0232.
Last Published 04.01.2021
This policy addresses direct and indirect noninvasive tests of carotid function. Applicable Procedure Codes: 92260, 93880, 93882, 93886, 93888, 93890, 93892, 93893.
Last Published 04.01.2021
This policy addresses diagnostic tests that are obsolete and have been replaced by more advanced procedures. Applicable Procedure Codes: 82495, 84999, 86486, 86849, P2028, P2029, P2033, P2038.
Last Published 07.01.2021
This policy addresses ocular photodynamic therapy (OPT) used in the treatment of ophthalmologic diseases, including age-related macular degeneration (AMD).
Last Published 08.01.2021
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 06.01.2021
This policy addresses the Ornish Program for Reversing Heart Disease as an intensive cardiac rehabilitation (ICR) program.
Last Published 04.01.2021
This policy addresses electrical and ultrasonic osteogenic stimulators. Applicable Procedure Codes: E0747, E0748, E0749, E0760.
Last Published 09.01.2021
This policy addresses osteopathic manipulative treatment (OMT). Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929.
Last Published 05.01.2021
This policy addresses outpatient intravenous (IV) insulin therapy (OIVIT). Applicable Procedure Codes: 94681, 99199, G9147.
Last Published 05.01.2021
This policy addresses carbon dioxide (5 percent) and oxygen (95 percent) inhalation therapy for the treatment of inner ear disease. Applicable Procedure Codes: 69949, 94799.
Last Published 08.01.2021
This policy addresses pancreas transplantation in diabetic patients. Applicable Procedure Codes: 48160, 48554.
Last Published 04.01.2021
This policy addresses partial ventriculectomy, also known as ventricular reduction, ventricular remodeling, or heart volume reduction surgery. Applicable Procedure Codes: 33548, 33999.
Last Published 08.01.2021
This policy addresses pediatric liver transplantation. Applicable Procedure Codes: 47135, 47399.
Last Published 04.01.2021
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 06.01.2021
This policy addresses percutaneous stereotactic or ultrasound image-guided biopsy for breast lesions. Applicable Procedure Codes: 19081, 19082, 19083, 19084, 19085, 19086.
Last Published 09.01.2021
This policy addresses percutaneous image-guided lumbar decompression (PILD) for lumbar spinal stenosis. Applicable Procedure Codes: 0275T, G0276.
Last Published 07.01.2021
This policy addresses percutaneous left atrial appendage closure (LAAC). Applicable Procedure Code: 33340.
Last Published 04.01.2021
This policy addresses percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain. Applicable Procedure Code: 27279.
Last Published 04.01.2021
This policy addresses percutaneous transluminal angioplasty (PTA). Applicable Procedure Codes: 37215, 37799.
Last Published 08.01.2021
This policy addresses percutaneous insertion of an endovascular cardiac (ventricular) assist device. Applicable Procedure Codes: 33990, 33991, 33992, 33993, 33995, 33997.
Last Published 09.01.2021
This policy addresses cataract extraction utilizing the phacoemulsification procedure. Applicable Procedure Codes: 66982, 66983, 66984. 66987, 66988.
Last Published 04.01.2021
This policy addresses pharmacogenomic testing for warfarin response. Applicable Procedure Code: G9143.
Last Published 07.01.2021
This policy addresses the use of ocular photodynamic therapy (OPT) for the treatment of ophthalmologic diseases. Applicable Procedure Codes: 67221, 67225.
Last Published 07.01.2021
This policy addresses photosensitive drugs used in photodynamic therapy. Applicable Procedure Code: J3396.
Last Published 04.01.2021
This policy addresses implantation of a phrenic nerve stimulator for the treatment of partial or complete respiratory insufficiency. Applicable Procedure Codes: L8679, L8680, L8681, L8683, L8685, L8686, L8687, L8688, L8689, L8695.
Last Published 09.01.2021
This policy addresses plastic surgery to correct "moon face". Applicable Procedure Codes: 15824, 15825, 15826, 15828, 15829.
Last Published 04.01.2021
This policy addresses plethysmography procedures. Applicable Procedure Codes: 94726, 94729, 94750, 93922, 93923, 93924.
Last Published 05.01.2021
This policy addresses pneumatic devices for the treatment of lymphedema and for chronic venous insufficiency with venous stasis ulcers. Applicable Procedure Codes: 99199, A4600, E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Last Published 04.01.2021
This policy addresses podiatry services pertaining to routine foot care. Applicable Procedure Codes: 11055, 11056, 11057, 11719, 11720, 11721, G0127, G0245, G0246, G0247.
Last Published 04.01.2021
This policy addresses porcine (pig) skin dressings and gradient pressure dressings. Applicable Procedure Codes: 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 04.01.2021
This policy addresses positron emission tomography (PET) scans.
Last Published 04.01.2021
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 06.01.2021
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, E0196, E0197, E0198, E0199, E0277, E0371, E0372, E0373, E1399.
Last Published 04.01.2021
This policy addresses prolotherapy with sclerosing agents. Applicable Procedure Code: M0076.
Last Published 08.01.2021
This policy addresses prostate cancer screening tests, including screening digital rectal examinations and screening prostate specific antigen tests. Applicable Procedure Codes: G0102, G0103.
Last Published 08.01.2021
This policy addresses prostate rectal spacers for use in men receiving radiation therapy for prostate cancer. Applicable Procedure Code: 55874.
Last Published 04.01.2021
This policy addresses prosthetic shoes. Applicable Procedure Code: L3250.
Last Published 05.01.2021
This policy addresses qualitative/presumptive drug screening/tests for indications other than mental health. Applicable Procedure Codes: 80305, 80306, 80307.
Last Published 08.01.2021
This policy addresses the use of refractive keratoplasty to correct vision problems. Applicable Procedure Codes: 65760, 65765, 65767, 65771.
Last Published 09.01.2021
This policy addresses electronic retinal prosthesis. Applicable Procedure Code: 0100T.
Last Published 08.01.2021
This policy addresses routine costs of qualifying clinical trials.
Last Published 04.01.2021
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 09.01.2021
This policy addresses scalp hypothermia during chemotherapy to prevent hair loss. Applicable Procedure Codes: 97010, E1399.
Last Published 08.01.2021
This policy addresses the use of a scleral shell (or shield). Applicable Procedure Codes: L9900, V2627.
Last Published 08.01.2021
This policy addresses screening and behavioral counseling interventions in primary care to reduce alcohol misuse in adults. Applicable Procedure Codes: G0442, G0443.
Last Published 06.01.2021
This policy addresses screening for cervical cancer with human papillomavirus (HPV) testing. Applicable Procedure Code: G0476.
Last Published 09.01.2021
This policy addresses screening for depression in adults. Applicable Procedure Code: G0444.
Last Published 07.01.2021
This policy addresses screening for the hepatitis B virus (HBV) infection. Applicable Procedure Codes: 86704, 86706, 87340, 87341, G0499.
Last Published 04.01.2021
This policy addresses screening for the hepatitis C virus (HCV) infection in adults. Applicable Procedure Code: G0472
Last Published 04.01.2021
This policy addresses screening for sexually transmitted infections (STIs) and high-intensity behavioral counseling (HIBC) to prevent STIs. Applicable Procedure Codes: 86592, 86593, 86631, 86632, 86780, 87110, 87270, 87320, 87490, 87491, 87590, 87591, 87800, 87810, 87850, G0445.
Last Published 07.01.2021
This policy addresses screening for the human immunodeficiency virus (HIV) infection. Applicable Procedure Codes: 80081, G0432, G0433, G0435, G0475.
Last Published 04.01.2021
This policy addresses screening pap smears and pelvic examinations for early detection of cervical or vaginal cancer. Applicable Procedure Codes: G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091.
Last Published 07.01.2021
This policy addresses the rental or purchase of seat lifts. Applicable Procedure Codes: E0172, E0627, E0629.
Last Published 05.01.2021
This policy addresses drugs or biologicals that are usually self-administered by the patient.
Last Published 06.01.2021
This policy addresses self-contained pacemaker monitors, including digital electronic pacemaker monitors and audible/visible signal pacemaker monitors. Applicable Procedure Codes: E0610, E0615.
Last Published 04.01.2021
This policy addresses serologic testing for acquired immunodeficiency syndrome (AIDS). Applicable Procedure Code: 86689.
Last Published 04.01.2021
This policy addresses services provided for the diagnosis and treatment of diabetic sensory neuropathy with loss of protective sensation (a.k.a. diabetic peripheral neuropathy). Applicable Procedure Codes: G0245, G0246, G0247.
Last Published 08.01.2021
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 04.01.2021
This policy addresses speech generating devices and accessories. Applicable Procedure Codes: E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599.
Last Published 04.01.2021
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 08.01.2021
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 04.01.2021
This policy addresses sterilization. Applicable Procedure Codes: 55250, 58565, 58600, 58605, 58611, 58615, 58670, 58671.
Last Published 05.01.2021
This policy addresses the use of supervised exercise therapy (SET) for the treatment of symptomatic peripheral artery disease (PAD) in patients with intermittent claudication (IC). Applicable Procedure Code: 93668.
Last Published 09.01.2021
This policy addresses surgical or other invasive procedure performed on the wrong body part, also known as “never events.”
Last Published 09.01.2021
This policy addresses surgical or other invasive procedure performed on the wrong patient, also known as “never events.”
Last Published 04.01.2021
This policy addresses sweat tests. Applicable Procedure Codes: 82438, 89230.
Last Published 07.01.2021
This policy addresses the use of the Sykes hernia control for the treatment of reducible hernia. Applicable Procedure Code: L8499.
Last Published 08.01.2021
This policy addresses injectable testosterone pellets (Testopel®). Applicable Procedure Codes: 11980, J3490.
Last Published 06.01.2021
This policy addresses the Pritikin Program as an intensive cardiac rehabilitation (ICR) program.
Last Published 09.01.2021
This policy addresses therapeutic continuous blood glucose monitoring (CGM) systems. Applicable Procedure Codes: 0446T, 0447T, 0448T, A9270, A9276, A9277, A9278, K0553, K0554.
Last Published 04.01.2021
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 08.01.2021
This policy addresses thermogenic therapy. Applicable Procedure Codes: 93799, 97799, 99199.
Last Published 05.01.2021
This policy addresses thermography. Applicable Procedure Codes: 76498, 93740.
Last Published 09.01.2021
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 04.01.2021
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 06.01.2021
This policy addresses transcatheter mitral valve repair (TMVR) for the treatment of mitral regurgitation. Applicable Procedure Codes: 0345T, 33418, 33419.
Last Published 08.01.2021
This policy addresses transcendental meditation (TM). Applicable Procedure Code: 90899.
Last Published 04.01.2021
This policy addresses transcranial magnetic stimulation (TMS). Applicable Procedure Codes: 90867, 90868, 90869.
Last Published 06.01.2021
This policy addresses transcutaneous electrical nerve stimulation (TENS) for the relief of acute post-operative pain. Applicable Procedure Codes: A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731.
Last Published 06.01.2021
This policy addresses transcutaneous electrical nerve stimulation (TENS) for chronic low back pain (CLBP). Applicable Procedure Codes: A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731.
Last Published 04.01.2021
This policy addresses transfer factor for treatment of multiple sclerosis. Applicable Procedure Code: 95199.
Last Published 04.01.2021
This policy addresses transmyocardial revascularization (TMR) for the treatment of severe angina. Applicable Procedure Codes: 33140, 33141.
Last Published 04.01.2021
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 07.16.2021
This policy addresses transtelephonic monitoring of cardiac pacemakers. Applicable Procedure Code: 93293.
Last Published 08.01.2021
This policy addresses transvenous (catheter) pulmonary embolectomy. Applicable Procedure Code: 37799.
Last Published 04.01.2021
This policy addresses treatment of actinic keratosis (AKs), also known as solar keratoses.
Last Published 04.01.2021
This policy addresses treatment of psoriasis. Applicable Procedure Codes: 96910, 96912, 96913, 96920, 96921, 96922.
Last Published 09.01.2021
This policy addresses tumor treatment field therapy. Applicable Procedure Codes: A4555, E0766.
Last Published 08.01.2021
This policy addresses ultrasonic surgery for the treatment of patients with severe and recurrent episodes of vertigo due to Meniere's syndrome. Applicable Procedure Code: 69949.
Last Published 09.01.2021
This policy addresses ultrasound diagnostic procedures utilizing low energy sound waves.
Last Published 07.01.2021
This policy addresses urological supplies related to urinary catheters and external urinary collection devices.
Last Published 09.01.2021
This policy addresses use of visual tests prior to and general anesthesia during cataract surgery. Applicable Procedure Codes: 00140, 00142, 76510, 76511, 76512, 76513, 76516, 76519, 92002, 92004, 92012, 92014, 92136.
Last Published 08.01.2021
This policy addresses vaccinations/immunizations.
Last Published 04.01.2021
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 08.01.2021
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 09.01.2021
This policy addresses percutaneous vertebral augmentation and percutaneous vertebroplasty. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515, 22899.
Last Published 04.01.2021
This policy addresses vertebral axial decompression (VAX-D) for the treatment of pain associated with lumbar disk problems. Applicable Procedure Codes: 97039, 97799.
Last Published 07.01.2021
This policy addresses verteporfin for the treatment of neovascular age-related macular degeneration (AMD).
Last Published 04.01.2021
This policy addresses vitamin B12 injections to strengthen tendons, ligaments, etc., of the foot. Applicable Procedure Code: J3420.
Last Published 05.01.2021
This policy addresses testing for vitamin D deficiency. Applicable Procedure Codes: 82306, 82652.
Last Published 08.01.2021
This policy addresses vitrectomy for the treatment of vitreous loss incident to cataract surgery, vitreous opacities due to vitreous hemorrhage or other causes, retinal detachments secondary to vitreous strands, proliferative retinopathy, and vitreous retraction. Applicable Procedure Codes: 67036, 67039, 67040, 67041, 67042, 67043.
Last Published 09.01.2021
This policy addresses wrong surgical or other invasive procedure performed on a patient, also called "never events."
Last Published 04.01.2021
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 04.01.2021
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 09.01.2021
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.