Archived Medical Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
- Abortion
- Abortion
- Abortion
- Acute In-Patient Detoxification (Opioid) PA Criteria
- Acute In-Patient Detoxification (Opioid) Prior Authorization Criteria
- Air Ambulance Transportation
- Applied Behavior Analysis (ABA)
- Applied Behavior Analysis for Autism Spectrum Disorder
- Applied Behavior Analysis Therapy for Autism Spectrum Disorder
- Applied Behavior Analysis Therapy for Autism Spectrum Disorder
- Applied Behavioral Analysis (ABA) Therapy
- Applied Behavioral Analysis Therapy for Autism Spectrum Disorder
- Applied Behavioral Analysis Therapy for Autism Spectrum Disorder
B
- Breast Cancer Index® (BCI) for Managing Breast Cancer Treatment
- Breast Imaging
- Breast Pumps and Lactation Services
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery
- Breast Reconstruction Surgery Following Mastectomy
- Breast Reconstruction Surgery Following Mastectomy
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
- Breast Reduction Surgery
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)
- Continuous Glucose Monitoring (CGM)
- Continuous Glucose Monitoring (CGM)
- Continuous Glucose Monitoring Systems (CGMS)
- Continuous Glucose Monitoring Systems (CGMS)
- Continuous Glucose Monitors
D
E
- Electrodiagnostic Testing: Nerve Conduction and Needle Electromyography Automated Nerve Conduction Studies
- Electrodiagnostic Testing: Nerve Conduction and Needle Electromyography Automated Nerve Conduction Studies
- Electrodiagnostic Testing: Nerve Conduction and Needle Electromyography Automated Nerve Conduction Studies
- Emergency Response Systems
- Emergency Response Systems
- Epidural Steroid Injections
- Epidural Steroid Injections
- Epidural Steroid Injections
- Epidural Steroid Injections
- Epidural Steroid Injections
- Epidural Steroid Injections
- Epidural Steroid Injections (Interlaminar, Transforaminal or Caudal Epidural Injections)
- Experimental or Investigational Technologies
F
- Facet Joint Interventions
- Facet Joint Interventions
- Facet Joint Interventions
- Facet Joint Interventions
- Facet Joint Interventions
- Facet Medial Branch Nerve Blocks
- Facet Medial Branch Nerve Blocks
- Facet Neurotomy
- Fraction Flow Reserve from computer tomography (FFRct)
- Fraction Flow Reserve from computer tomography (FFRct)
- Fraction Flow Reserve from computer tomography (FFRct)
G
- Gender Affirming Surgery
- Gender Affirming Surgery
- Gender Affirming Surgery
- Gender Affirming Surgery
- Gender Affirming Surgery
- Gender Dysphoria
- Gender Dysphoria
- Genetic Testing and Counseling
- Genetic Testing and Counseling
- Genetic Testing and Counseling
- Genetic Testing and Counseling
- Genetic Testing and Counseling
- Genetic Testing, Genetic Screening and Genetic Counseling
- Genetic Testing, Genetic Screening and Genetic Counseling
H
- Home Medication Dispenser Devices
- Home Medication Dispenser Devices
- Hospital Safety Beds
- Hyperthermic Intraperitoneal Chemotherapy
- Hyperthermic Intraperitoneal Chemotherapy
- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
- Hypoglossal Nerve Stimulation for the Treatment of OSA
I
- 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
- Inhaled Nitric Oxide
- Inhaled Nitric Oxide
- Insulin Infusion Pump
- Insulin Infusion Pump
- Insulin Infusion Pump
- Insulin Infusion Pump
- Insulin Infusion Pump Therapy for Diabetes
- Insulin Infusion Pump Therapy for Diabetes
- Intraosseous Basivertebral Nerve Ablation
- Intraosseous Basivertebral Nerve Ablation
- Intraosseous Basivertebral Nerve Ablation
K
L
M
- Mastectomy for Gynecomastia
- Mechanical Stretching Devices
- Mechanical Stretching Devices
- Minimally Invasive Gastroesophageal Reflux Disease (GERD) Treatment
- Myoelectric Lower Extremity Orthotic Technology
- Myoelectric Lower Extremity Prosthetic Technology
- Myoelectric Lower Extremity Prosthetic Technology
N
- National and Local Coverage Determinations
- Negative Pressure Wound Therapy
- Negative Pressure Wound Therapy (NPWT)
- Negative Pressure Wound Therapy (NPWT)
- Negative Pressure Wound Therapy (NPWT)
- Negative Pressure Wound Therapy (NPWT)
- Neonatal Discharge Criteria
- Neonatal Discharge Criteria
- Neonatal Discharge Criteria
- No Policy Determinations
- Non-Emergency Facility to Facility Transfers
- Nutritional Supplement
- Nutritional Supplement
- Nutritional Supplement
- Nutritional Supplement
- Nutritional Supplements
- Nutritional Supplements
- Nutritional Supplements
O
P
- Pain Management Interventional Procedures
- Peripheral Nerve Blocks for Treatment of Pain
- Peripheral Nerve Stimulators for the Treatment of Pain
- Peripheral Nerve Stimulators for Treatment of Pain
- Peroral Endoscopic Myotomy
- Peroral Endoscopic Myotomy (POEM)
- Personal Emergency Response System
- Personal Emergency Response System
- Personal Emergency Response Systems
- Personal Emergency Response Systems
- Positive Airway Pressure Devices for Pulmonary Disorders
- Positive Airway Pressure Devices for Pulmonary Disorders
- Positive Airway Pressure Devices for Pulmonary Disorders
- ProACT Adjustable Continence Therapy
- ProACT Adjustable Continence Therapy
R
S
- Sacroiliac Joint Fusion
- Sacroiliac Joint Fusion
- Sacroiliac Joint Fusion
- Sacroiliac Joint Injection
- Sacroiliac Joint Procedures
- Sacroiliac Joint Procedures
- Sacroiliac Joint Procedures
- Sacroiliac Joint Procedures
- Sacroiliac Joint Procedures
- Safety Beds
- Saphenous Vein Ablation, Adhesive Injection
- Screening and Diagnostic Mammography
- Screening and Surveillance for Colorectal Cancer
- Screening and Surveillance for Colorectal Cancer
- Serum Biomarker Panel Testing in Systemic Lupus Erythematosus and Rheumatoid Arthritis
- Serum Biomarker Panel Testing in Systemic Lupus Erythematosus and Rheumatoid Arthritis
- Serum Biomarker Panel Testing in Systemic Lupus Erythematosus and Rheumatoid Arthritis
- Serum Biomarker Panel Testing in Systemic Lupus Erythematosus and Rheumatoid Arthritis
- Skin Substitutes
- Sleep Studies
- Special Needs Car Seats
- Stab Phlebectomy
- Stab Phlebectomy
- Standing Frames
- Standing Frames
T
- Temporomandibular Joint Disorder or Dysfunction (TMJD/TMD) Craniomandibular Jaw Disorder/Non Surgical Treatment
- Temporomandibular Joint Disorder or Dysfunction (TMJD/TMD) Craniomandibular Jaw Disorder/Non-Surgical Treatment
- Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation
- Transcranial Magnetic Stimulation for Treatment of Depression
- Transcranial Magnetic Stimulation for Treatment of Depression
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections
- Trigger Point Injections