Archived Medical Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
B
C
- CAR-T Medications - Abecma
- CAR-T Medications - Breyanzi
- CAR-T Medications - Kymriah
- CAR-T Medications - Tecartus
- CAR-T Medications - Yescarta
- CAR-T medications – Kymriah (tisagenlecleucel)
- CAR-T medications – Tecartus (brexucabtagene autoleucel)
- CAR-T medications – Yescarta (axicabtagene ciloleucel)
- Clinical Trial Coverage
- Clinical Trial Coverage - Archived on 12/31/2022
- Continuous Glucose Monitoring (CGM)
- Continuous Glucose Monitoring (CGM)
- Continuous Glucose Monitoring Systems (CGMS)
- Continuous Glucose Monitors
D
E
F
- Facet Joint Interventions
- Facet Joint Interventions
- Facet Joint Interventions
- Facet Medial Branch Nerve Blocks
- Facet Medial Branch Nerve Blocks
- Fecal Microbiota Installation
- Fecal Microbiota Installation
- Fraction Flow Reserve from computer tomography (FFRct)
- Fraction Flow Reserve from Computer Tomography (FFRct)
G
H
I
- Impacted Cerumen Removal
- Impacted Cerumen Removal
- Implantable Pain Pump
- Implantable Pain Pump
- Implantable Pain Pump
- Implantable Pain Pump
- Implantable Spinal Cord Stimulator
- Implantable Spinal Cord Stimulator
- Implantable Spinal Cord Stimulator
- Implantable Spinal Cord Stimulator
- Infant Formula
- Inhaled Nitric Oxide
- Inhaled Nitric Oxide
- Inhaled Nitric Oxide
- Inhaled Nitric Oxide for Neonates
- Insulin Infusion Pump
- Insulin Infusion Pump
- Insulin Infusion Pump
L
M
- Mastectomy for Gynecomastia
- Mastectomy for Gynecomastia
- Mastectomy for Gynecomastia
- Mastectomy for Gynecomastia
- Metabolic and Bariatric Surgery - Revision
- Metabolic and Bariatric Surgery - Revision
- Metabolic and Bariatric Surgery for < 18 Years of Age
- Metabolic and Bariatric Surgery for < 18 Years of Age
- Metabolic and Bariatric Surgery for 18 years of age and Older
- Metabolic and Bariatric Surgery for 18 years of age and Older
- Metabolic and Bariatric Surgery in Adolescents
- Metabolic and Bariatric Surgery in Adults 20 and Older
- Microwave Ablation of Tumors
- Minimally Invasive Gastroesophageal Reflux Disease (GERD) Treatment
- Myoelectric Lower Extremity Prosthetic Technology
N
- Negative Pressure Wound Therapy (NPWT)
- Negative Pressure Wound Therapy (NPWT)
- Negative Pressure Wound Therapy (NPWT)
- Negative Pressure Wound Therapy (NPWT)
- Neonatal Discharge Criteria
- Non-Emergency Facility to Facility Transfers
- Non-Invasive Vascular Studies
- Nutritional Supplements
- Nutritional Supplements
- Nutritional Supplements
- Nutritional Supplements
O
P
R
S
T
- Thyroid Testing
- Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation
- Transthoracic Echocardiogram
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Tumor Treatment Field Devices for Glioblastoma Multiforme