Medical Policies - Medical
Accelerated Partial Breast Irradiation Commercial - Medical 207
PDF, 206 KB
PDF, 206 KB
Accelerated Partial Breast Irradiation Medicaid - Medical 207
PDF, 279 KB
PDF, 279 KB
Actigraphy Commercial - Medical 259
PDF, 186 KB
PDF, 186 KB
Actigraphy Medicaid - Medical 259
PDF, 237 KB
PDF, 237 KB
Agile Patency System Commercial - Medical 131
PDF, 164 KB
PDF, 164 KB
Agile Patency System Medicaid - Medical 131
PDF, 211 KB
PDF, 211 KB
Ambulance Transport Services Commercial - Medical 105
PDF, 218 KB
PDF, 218 KB
Ambulance Transport Services Medicaid - Medical 105
PDF, 293 KB
PDF, 293 KB
Apheresis Commercial - Medical 128
PDF, 251 KB
PDF, 251 KB
Apheresis Medicaid - Medical 128
PDF, 320 KB
PDF, 320 KB
Apixaban (Eliquis) Drug Level Commercial - Medical 303
PDF, 166 KB
PDF, 166 KB
Apixaban (Eliquis) Drug Level Medicaid - Medical 303
PDF, 234 KB
PDF, 234 KB
Apixaban (Eliquis) Drug Level Medicare - Medical 303
PDF, 194 KB
PDF, 194 KB
Autologous Myoblast and Muscle Cell Injection Commercial - Medical 262
PDF, 219 KB
PDF, 219 KB
Autologous Myoblast and Muscle Cell Injection Medicaid - Medical 262
PDF, 255 KB
PDF, 255 KB
Autologous Myoblast and Muscle Cell Injection Medicare - Medical 262
PDF, 213 KB
PDF, 213 KB
Autologous Serum Tears Commercial - Medical 244
PDF, 187 KB
PDF, 187 KB
Autologous Serum Tears Medicaid - Medical 244
PDF, 210 KB
PDF, 210 KB
Autologous Serum Tears Medicare - Medical 244
PDF, 213 KB
PDF, 213 KB
Automated Nerve Conduction Testing Commercial - Medical 250
PDF, 190 KB
PDF, 190 KB
Automated Nerve Conduction Testing Medicaid - Medical 250
PDF, 243 KB
PDF, 243 KB
Bone Scaffolding Commercial - Medical 02
PDF, 225 KB
PDF, 225 KB
Bone Scaffolding Medicaid - Medical 02
PDF, 307 KB
PDF, 307 KB
Brachytherapy Commercial - Medical 71
PDF, 228 KB
PDF, 228 KB
Brachytherapy Medicaid - Medical 71
PDF, 305 KB
PDF, 305 KB
Bronchial Thermoplasty for the Treatment of Asthma Commercial - Medical 285
PDF, 164 KB
PDF, 164 KB
Bronchial Thermoplasty for the Treatment of Asthma Medicaid - Medical 285
PDF, 211 KB
PDF, 211 KB
Bronchial Thermoplasty for the Treatment of Asthma Medicare - Medical 285
PDF, 192 KB
PDF, 192 KB
Bulking Agents for Vocal Cord Insufficiency Commercial - Medical 153
PDF, 204 KB
PDF, 204 KB
Bulking Agents for Vocal Cord Insufficiency Medicaid - Medical 153
PDF, 265 KB
PDF, 265 KB
Bulking Agents for Vocal Cord Insufficiency Medicare - Medical 153
PDF, 234 KB
PDF, 234 KB
Capsule Endoscopy Commercial - Medical 81
PDF, 221 KB
PDF, 221 KB
Capsule Endoscopy Medicaid - Medical 81
PDF, 290 KB
PDF, 290 KB
Category III codes Commercial - Medical 336
PDF, 333 KB
PDF, 333 KB
Category III codes Medicaid - Medical 336
PDF, 509 KB
PDF, 509 KB
Cell Enumeration Commercial - Medical 310
PDF, 165 KB
PDF, 165 KB
Cell Enumeration Medicaid - Medical 310
PDF, 233 KB
PDF, 233 KB
Chemotherapy Administration Commercial - Medical 316
PDF, 201 KB
PDF, 201 KB
Chemotherapy Administration Medicaid - Medical 316
PDF, 231 KB
PDF, 231 KB
Chiropractic Services Commercial - Medical 182
PDF, 293 KB
PDF, 293 KB
Chromoendoscopy Commercial - Medical 283
PDF, 208 KB
PDF, 208 KB
Chromoendoscopy Medicaid - Medical 283
PDF, 263 KB
PDF, 263 KB
Chromoendoscopy Medicare - Medical 283
PDF, 229 KB
PDF, 229 KB
Colonic Lavage Therapy Commercial - Medical 178
PDF, 136 KB
PDF, 136 KB
Colonic Lavage Therapy Medicaid - Medical 178
PDF, 231 KB
PDF, 231 KB
Corneal Cross-Linking Commercial - Medical 264
PDF, 188 KB
PDF, 188 KB
Corneal Cross-Linking Medicaid - Medical 264
PDF, 286 KB
PDF, 286 KB
Corneal Cross-Linking Medicare - Medical 264
PDF, 241 KB
PDF, 241 KB
Corneal Hysteresis Measurement Commercial - Medical 265
PDF, 161 KB
PDF, 161 KB
Corneal Hysteresis Measurement Medicaid - Medical 265
PDF, 188 KB
PDF, 188 KB
Dermal Fillers Commercial - Medical 201
PDF, 203 KB
PDF, 203 KB
Dermal Fillers Medicaid - Medical 201
PDF, 276 KB
PDF, 276 KB
Dry Hydrotherapy Commercial - Medical 267
PDF, 190 KB
PDF, 190 KB
Dry Hydrotherapy Medicaid - Medical 267
PDF, 241 KB
PDF, 241 KB
Dry Needling Commercial - Medical 173
PDF, 138 KB
PDF, 138 KB
Dry Needling Medicaid - Medical 173
PDF, 212 KB
PDF, 212 KB
Early Inpatient Admission Commercial - Medical 145
PDF, 205 KB
PDF, 205 KB
Early Inpatient Admission Medicaid - Medical 145
PDF, 252 KB
PDF, 252 KB
Electric Cell-Signaling Energy Waves (EcST and ESI) Commercial - Medical 179
PDF, 150 KB
PDF, 150 KB
Electric Cell-Signaling Energy Waves (EcST and ESI) Medicaid - Medical 179
PDF, 191 KB
PDF, 191 KB
Electrical Bioimpedance Commercial - Medical 118
PDF, 140 KB
PDF, 140 KB
Electrical Bioimpedance Medicaid - Medical 118
PDF, 212 KB
PDF, 212 KB
Ellipsys Vascular Access System Commercial - Medical 318
PDF, 167 KB
PDF, 167 KB
Ellipsys Vascular Access System Medicaid - Medical 318
PDF, 241 KB
PDF, 241 KB
Enteral and Parenteral Feeding and Intradialytic Parenteral Nutrition Commercial - Medical 13
PDF, 236 KB
PDF, 236 KB
Enteral and Parenteral Feeding and Intradialytic Parenteral Nutrition Medicaid - Medical 13
PDF, 490 KB
PDF, 490 KB
Equestrian Therapy (e.g., Hippotherapy) Commercial - Medical 268
PDF, 136 KB
PDF, 136 KB
Equestrian Therapy (e.g., Hippotherapy) Medicaid - Medical 268
PDF, 273 KB
PDF, 273 KB
Equestrian Therapy (e.g., Hippotherapy) Medicare - Medical 268
PDF, 189 KB
PDF, 189 KB
Erector Spinae Plane Block Commercial - Medical 332
PDF, 219 KB
PDF, 219 KB
Erector Spinae Plane Block Medicaid - Medical 332
PDF, 226 KB
PDF, 226 KB
Erector Spinae Plane Block Medicare - Medical 332
PDF, 239 KB
PDF, 239 KB
Eustachian tube balloon dilation (ETBD) Tuboplasty Commercial - Medical 328
PDF, 210 KB
PDF, 210 KB
Eustachian tube balloon dilation (ETBD) Tuboplasty Medicaid - Medical 328
PDF, 263 KB
PDF, 263 KB
Eustachian tube balloon dilation (ETBD) Tuboplasty Medicare - Medical 328
PDF, 249 KB
PDF, 249 KB
Exhaled Breath Condensate (EBC ph) Commercial - Medical 286
PDF, 186 KB
PDF, 186 KB
Exhaled Breath Condensate (EBC ph) Medicaid - Medical 286
PDF, 221 KB
PDF, 221 KB
Exhaled Breath Condensate (EBC ph) Medicare - Medical 286
PDF, 193 KB
PDF, 193 KB
Extracorporeal Photopheresis Commercial - Medical 237
PDF, 180 KB
PDF, 180 KB
Extracorporeal Photopheresis Medicaid - Medical 237
PDF, 254 KB
PDF, 254 KB
Fecal Bacteriotherapy Commercial - Medical 181
PDF, 181 KB
PDF, 181 KB
Fecal Bacteriotherapy Medicaid - Medical 181
PDF, 232 KB
PDF, 232 KB
Fecal Bacteriotherapy Medicare - Medical 181
PDF, 212 KB
PDF, 212 KB
Fecal Incontinence Treatments Commercial - Medical 300
PDF, 210 KB
PDF, 210 KB
Fecal Incontinence Treatments Medicaid - Medical 300
PDF, 290 KB
PDF, 290 KB
Fetal Magnetic Cardiac Signal Commercial - Medical 297
PDF, 218 KB
PDF, 218 KB
Fetal Magnetic Cardiac Signal Medicaid -Medical 297
PDF, 286 KB
PDF, 286 KB
Fetal Magnetic Cardiac Signal Medicare - Medical 297
PDF, 246 KB
PDF, 246 KB
Gait analysis and surface electromyography Commercial - Medical 345.pdf
PDF, 232 KB
PDF, 232 KB
Gait Analysis and Surface Electromyography Medicaid - Medical 345.pdf
PDF, 254 KB
PDF, 254 KB
Gait Analysis and Surface Electromyography Medicare - Medical 345.pdf
PDF, 238 KB
PDF, 238 KB
Galectin 3 (LGALS3) Commercial - Medical 304
PDF, 218 KB
PDF, 218 KB
Galectin 3 (LGALS3) Medicaid - Medical 304
PDF, 345 KB
PDF, 345 KB
Galectin 3 (LGALS3) Medicare - Medical 304
PDF, 266 KB
PDF, 266 KB
Genetic Testing - Cardioneurovascular and Developmental Diagnosis Commercial - Medical 34C
PDF, 373 KB
PDF, 373 KB
Genetic Testing - Cardioneurovascular and Developmental Diagnosis Medicaid - Medical 34C
PDF, 408 KB
PDF, 408 KB
Genetic Testing - Cardioneurovascular and Developmental Diagnosis Medicare - Medical 34C
PDF, 406 KB
PDF, 406 KB
Genetic Testing - Preconceptional-Prenatal-Preimplantation Commercial - Medical 34D
PDF, 298 KB
PDF, 298 KB
Genetic Testing - Preconceptional-Prenatal-Preimplantation Medicaid - Medical 34D
PDF, 399 KB
PDF, 399 KB
Genetic Testing - Preconceptional-Prenatal-Preimplantation Medicare - Medical 34D
PDF, 334 KB
PDF, 334 KB
Genetic Testing - Pre-Treatment or Post-Intervention Commercial - Medical 34B
PDF, 248 KB
PDF, 248 KB
Genetic Testing - Pre-Treatment or Post-Intervention Medicaid - Medical 34B
PDF, 294 KB
PDF, 294 KB
Genetic Testing - Pre-Treatment or Post-Intervention Medicare - Medical 34B
PDF, 282 KB
PDF, 282 KB
Genetic Testing-Cancer Prevention, Diagnosis and Treatment Commercial - Medical 34A
PDF, 625 KB
PDF, 625 KB
Genetic Testing-Cancer Prevention, Diagnosis and Treatment Medicaid - Medical 34A
PDF, 632 KB
PDF, 632 KB
Genetic Testing-Cancer Prevention, Diagnosis and Treatment Medicare - Medical 34A
PDF, 714 KB
PDF, 714 KB
Genicular Artery Embolization (GAE) Commercial - Medical 342
PDF, 208 KB
PDF, 208 KB
Genicular Artery Embolization (GAE) Medicaid - Medical 342
PDF, 257 KB
PDF, 257 KB
Heartsbreath Test Commercial - Medical 257
PDF, 186 KB
PDF, 186 KB
Heartsbreath Test Medicaid - Medical 257
PDF, 232 KB
PDF, 232 KB
Home Health Aide Commercial - Medical 144
PDF, 189 KB
PDF, 189 KB
Home Health Aide Medicaid - Medical 144
PDF, 237 KB
PDF, 237 KB
Home Health Aide Medicare - Medical 144
PDF, 217 KB
PDF, 217 KB
Immunoglobulin Light Chains Commercial - Medical 333
PDF, 193 KB
PDF, 193 KB
Immunoglobulin Light Chains Medicaid - Medical 333
PDF, 234 KB
PDF, 234 KB
Immunoglobulin Light Chains Medicare - Medical 333
PDF, 221 KB
PDF, 221 KB
Implantable Hemodynamic Monitoring for Heart Failure Commercial - Medical 317
PDF, 188 KB
PDF, 188 KB
Implantable Hemodynamic Monitoring for Heart Failure Medicaid - Medical 317
PDF, 235 KB
PDF, 235 KB
Implantable Hemodynamic Monitoring for Heart Failure Medicare - Medical 317
PDF, 237 KB
PDF, 237 KB
Infrared Light Therapy and Low-Level Laser Therapy Commercial - Medical 109
PDF, 195 KB
PDF, 195 KB
Infrared Light Therapy and Low-Level Laser Therapy Medicaid - Medical 109
PDF, 267 KB
PDF, 267 KB
Ingestible Devices Commercial - Medical 344
PDF, 160 KB
PDF, 160 KB
Ingestible Devices Medicaid Medical 344.pdf
PDF, 230 KB
PDF, 230 KB
Ingestible Devices Medicare - Medical 344
PDF, 202 KB
PDF, 202 KB
Ingestion Challenge Test or Double Blind Food Challenge Commercial - Medical 140
PDF, 212 KB
PDF, 212 KB
Injectable Hormone Pellets Commercial - Medical 157
PDF, 187 KB
PDF, 187 KB
Injectable Hormone Pellets Medicaid - Medical 157
PDF, 232 KB
PDF, 232 KB
Intensive Cardiac Rehabilitation Programs Commercial - Medical 52
PDF, 205 KB
PDF, 205 KB
Intensive Cardiac Rehabilitation Programs Medicaid - Medical 52
PDF, 274 KB
PDF, 274 KB
Intra-arterial (IA) Chemotherapy Commercial - Medical 254
PDF, 277 KB
PDF, 277 KB
Intra-arterial (IA) Chemotherapy Medicaid - Medical 254
PDF, 295 KB
PDF, 295 KB
Keratoconus Lenses and Interventions-Piggyback Contact Lenses Commercial - Medical 03
PDF, 288 KB
PDF, 288 KB
Keratoconus Lenses and Interventions-Piggyback Contact Lenses Medicaid - Medical 03
PDF, 312 KB
PDF, 312 KB
Lodging and Meal Reimbursement Medicaid Medical 169
PDF, 247 KB
PDF, 247 KB
Lodging and Meal Reimbursement Medicare - Medical 169
PDF, 211 KB
PDF, 211 KB
Long-Term Care Hospital (LTACH) Services Medicaid - Medical 337
PDF, 290 KB
PDF, 290 KB
Long-Term Care Hospital (LTACH) Services Medicare - Medical 335
PDF, 244 KB
PDF, 244 KB
Miscellaneous Wound Management Therapies Commercial - Medical 177
PDF, 191 KB
PDF, 191 KB
Miscellaneous Wound Management Therapies Medicaid - Medical 177
PDF, 277 KB
PDF, 277 KB
Mitochondrial Antibody Testing Commercial - Medical 180.
PDF, 189 KB
PDF, 189 KB
Mitochondrial Antibody Testing Medicaid - Medical 180
PDF, 255 KB
PDF, 255 KB
Mitochondrial Antibody Testing Medicare - Medical 180
PDF, 222 KB
PDF, 222 KB
Mobile Cardiac Telemetry Commercial - Medical 112
PDF, 213 KB
PDF, 213 KB
Mobile Cardiac Telemetry Medicaid - Medical 112
PDF, 272 KB
PDF, 272 KB
Movement Disorder Analysis Commercial - Medical 298
PDF, 198 KB
PDF, 198 KB
Movement Disorder Analysis Medicaid - Medical 298
PDF, 233 KB
PDF, 233 KB
Movement Disorder Analysis Medicare - Medical 298
PDF, 225 KB
PDF, 225 KB
Muscle Pain Detector Commercial - Medical 247
PDF, 188 KB
PDF, 188 KB
Muscle Pain Detector Medicaid - Medical 247
PDF, 235 KB
PDF, 235 KB
Muscle Pain Detector Medicare - Medical 247
PDF, 215 KB
PDF, 215 KB
Nasal Function Studies Rhinomanometry-Rhinometry-Nasometry Commercial - Medical 260
PDF, 162 KB
PDF, 162 KB
Nasal Function Studies Rhinomanometry-Rhinometry-Nasometry Medicaid - Medical 260
PDF, 234 KB
PDF, 234 KB
Near-infrared Spectroscopy Commercial - Medical 330
PDF, 192 KB
PDF, 192 KB
Near-infrared Spectroscopy Medicaid - Medical 330
PDF, 217 KB
PDF, 217 KB
Neutron Beam Therapy (NBT) Commercial - Medical 202
PDF, 284 KB
PDF, 284 KB
Neutron Beam Therapy (NBT) Medicaid - Medical 202
PDF, 275 KB
PDF, 275 KB
Neutron Beam Therapy (NBT) Medicare - Medical 202
PDF, 232 KB
PDF, 232 KB
Non-Invasive Assessment of the Vasculature for Cardiovascular Risk Commercial - Medical 334
PDF, 210 KB
PDF, 210 KB
Non-Invasive Assessment of the Vasculature for Cardiovascular Risk Medicaid - Medical 334
PDF, 239 KB
PDF, 239 KB
Ocular Photoscreening Medicare - Medical 172
PDF, 236 KB
PDF, 236 KB
Optical Endomicroscopy Commercial - Medical 281
PDF, 200 KB
PDF, 200 KB
Phase II Cardiac Rehabilitation Commercial - Medical 51
PDF, 213 KB
PDF, 213 KB
Phase II Cardiac Rehabilitation Medicaid - Medical 51
PDF, 252 KB
PDF, 252 KB
Photodynamic Therapy for Oncologic and Dermatologic Conditions Commercial - Medical 77
PDF, 312 KB
PDF, 312 KB
Photodynamic Therapy for Oncologic and Dermatologic Conditions Medicaid - Medical 77
PDF, 324 KB
PDF, 324 KB
Photodynamic Therapy with Verteporfin Commercial - Medical 171
PDF, 208 KB
PDF, 208 KB
Photodynamic Therapy with Verteporfin Medicaid - Medical 171
PDF, 253 KB
PDF, 253 KB
Physical Therapy for Treating Obesity Commercial - Medical 252
PDF, 207 KB
PDF, 207 KB
Physical Therapy for Treating Obesity Medicaid - Medical 252
PDF, 261 KB
PDF, 261 KB
Physical Therapy for Treating Obesity Medicare - Medical 252
PDF, 231 KB
PDF, 231 KB
Platelet Rich-Plasma Commercial - Medical 246
PDF, 239 KB
PDF, 239 KB
Platelet Rich-Plasma Medicaid - Medical 246
PDF, 260 KB
PDF, 260 KB
Proton Beam Radiation Therapy (PBRT) Commercial - Medical 101
PDF, 224 KB
PDF, 224 KB
Proton Beam Radiation Therapy (PBRT) Medicaid - Medical 101.pdf
PDF, 264 KB
PDF, 264 KB
Quantitative Sensory Testing (QST) Commercial - Medical 127
PDF, 208 KB
PDF, 208 KB
Quantitative Sensory Testing (QST) Medicaid - Medical 127
PDF, 240 KB
PDF, 240 KB
Sclerotherapy and Prolotherapy for Joints and Tendons Commercial - Medical 108
PDF, 190 KB
PDF, 190 KB
Sclerotherapy and Prolotherapy for Joints and Tendons Medicaid - Medical 108
PDF, 217 KB
PDF, 217 KB
SmartPill Wireless Motility Capsule Commercial - Medical 212
PDF, 187 KB
PDF, 187 KB
SmartPill Wireless Motility Capsule Medicaid - Medical 212
PDF, 215 KB
PDF, 215 KB
Telemonitoring Services Medicaid - Medical 160
PDF, 262 KB
PDF, 262 KB
Telemonitoring Services Commercial - Medical 160
PDF, 236 KB
PDF, 236 KB
Telemonitoring Services Medicare - Medical 160
PDF, 236 KB
PDF, 236 KB
Transanal Double Balloon Enteroscopy Commercial - Medical 293
PDF, 258 KB
PDF, 258 KB
Transanal Double Balloon Enteroscopy Medicaid - Medical 293
PDF, 252 KB
PDF, 252 KB
Transanal Double Balloon Enteroscopy Medicare - Medical 293
PDF, 237 KB
PDF, 237 KB
Transarterial Embolization Direct Therapies (TAE, TACE and DEB-TACE) Commercial - Medical 139
PDF, 285 KB
PDF, 285 KB
Transarterial Embolization Direct Therapies (TAE, TACE and DEB-TACE) Medicaid - Medical 139
PDF, 306 KB
PDF, 306 KB
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Commercial - Medical 256
PDF, 223 KB
PDF, 223 KB
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Medicaid - Medical 256
PDF, 297 KB
PDF, 297 KB
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Medicare - Medical 256
PDF, 244 KB
PDF, 244 KB
Transplant Rejection Testing Commercial - Medical 99
PDF, 242 KB
PDF, 242 KB
Transplant Rejection Testing Medicaid - Medical 99
PDF, 290 KB
PDF, 290 KB
Tumor Treating Fields Therapy Commercial - Medical 166
PDF, 212 KB
PDF, 212 KB
Tumor Treating Fields Therapy Medicaid - Medical 166
PDF, 252 KB
PDF, 252 KB
Urinary Incontinence Treatments Commercial - Medical 130
PDF, 223 KB
PDF, 223 KB
Urinary Incontinence Treatments Medicaid - Medical 130
PDF, 269 KB
PDF, 269 KB
Vestibular Functioning Test Commercial - Medical 174
PDF, 205 KB
PDF, 205 KB
Vestibular Functioning Test Medicaid - Medical 174
PDF, 285 KB
PDF, 285 KB
Vestibular Rehabilitation Commercial - Medical 91
PDF, 213 KB
PDF, 213 KB
Vestibular Rehabilitation Medicaid - Medical 91
PDF, 264 KB
PDF, 264 KB
Vision Therapy for Convergence Insufficiency Commercial - Medical 324
PDF, 221 KB
PDF, 221 KB
Vision Therapy for Convergence Insufficiency Medicaid - Medical 324
PDF, 231 KB
PDF, 231 KB
Wound Treatment and Care Supplies (i.e. dressings, barriers and fillers) Commercial - Medical 343
PDF, 200 KB
PDF, 200 KB
Wound Treatment and Care Supplies (i.e. dressings, barriers and fillers) Medicaid - Medical 343
PDF, 244 KB
PDF, 244 KB
Wound Treatment and Care Supplies (i.e. dressings, barriers and fillers) Medicare - Medical 343
PDF, 227 KB
PDF, 227 KB