Medical Policies

By accessing our medical policies you signify your agreement to our Terms of Use. Learn more about how medical policies are developedOpen a PDF and about experimental & investigational procedures .

Please refer member-specific questions to the Customer Care number on the back of the member card. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service.

Make a comment

We invite practitioners to review & comment on our policies

or
Showing 251– 300 of 339 Results
Title Last Updated Category
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty (Effective 2026-10-15) Open a PDF 6.01.17 2026-07-15 Bone & Joints (Orthopedic)
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty Open a PDF 6.01.17 2025-07-11 Bone & Joints (Orthopedic)
Periodontal Maintenance Open a PDF 13.01.05 2026-07-21 Dental
Periodontal Scaling and Root Planing Open a PDF 13.01.04 2026-07-21 Dental
Peroral Endoscopic Myotomy (POEM) Procedures Open a PDF 7.01.120 2026-02-13 Digestive System (Gastroenterology)
Pharmacogenetics Open a PDF 2.02.30 2026-04-14 Genetic Disease (Inherited Disease)
Photodynamic Therapy for Malignant Disease Open a PDF 8.01.06 2026-04-28 Cancer Treatment (Oncology)
Platelet Rich Plasma and Growth Factor Treatments Open a PDF 2.01.24 2026-01-27 Skin (Dermatology)
Positive Airway Pressure Devices CPAP, BiPAP, APAP and Noninvasive Positive Pressure Ventilators Open a PDF 1.01.06 2025-10-22 Sleep Medicine
Positron Emission Tomography (PET) - Non-Oncologic Applications (Effective 2026-10-15) Open a PDF 6.01.07 2026-07-15 Radiology (x-rays) & Imaging
Positron Emission Tomography (PET) - Non-Oncologic Applications Open a PDF 6.01.07 2026-02-13 Radiology (x-rays) & Imaging
Positron Emission Tomography (PET) – Head Imaging Open a PDF 6.01.47 2026-02-13 Radiology (x-rays) & Imaging
Positron Emission Tomography (PET) Oncologic Applications (Effective 2026-10-15) Open a PDF 6.01.29 2026-07-15 Radiology (x-rays) & Imaging
Positron Emission Tomography (PET) Oncologic Applications Open a PDF 6.01.29 2026-02-13 Radiology (x-rays) & Imaging
Powered Compression Devices/Lymphedema Pumps Open a PDF 1.01.17 2026-01-15 Durable Medical Equipment & Supplies
Predictive Testing for Pancreatic Cancer Open a PDF 2.02.39 2025-12-23 Lab Tests (pathology)
Prenatal Genetic Testing Open a PDF 4.01.03 2026-03-17 Genetic Disease (Inherited Disease)
Private Rooms Open a PDF 12.01.06 2025-11-25 Miscellaneous
Prolotherapy (Effective 2026-10-15) Open a PDF 8.01.10 2026-07-15 Bone & Joints (Orthopedic)
Prolotherapy Open a PDF 8.01.10 2025-07-11 Bone & Joints (Orthopedic)
Proton Beam Radiation Therapy Open a PDF 6.01.11 2026-08-25 Radiation Treatment
Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation (Effective 2026-10-15) Open a PDF 7.01.42 2026-07-15 Bone & Joints (Orthopedic)
Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation Open a PDF 7.01.42 2025-07-11 Bone & Joints (Orthopedic)
Radiopharmaceuticals for the Treatment of Cancer Open a PDF 6.01.44 2026-09-21 Cancer Treatment (Oncology)
Reduction Mammaplasty (Mammoplasty) Open a PDF 7.01.39 2026-10-06 Cosmetic / Reconstructive Surgery
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy Open a PDF 7.01.103 2026-05-27 Nervous Systems (Neurology)
Sacral Nerve Stimulation Open a PDF 7.01.10 2025-12-16 Nervous Systems (Neurology)
Sacroiliac Joint Fusion or Stabilization (Effective 2026-10-15) Open a PDF 7.01.93 2026-07-15 Bone & Joints (Orthopedic)
Sacroiliac Joint Fusion or Stabilization Open a PDF 7.01.93 2025-07-15 Bone & Joints (Orthopedic)
Showing 251– 300 of 339 Results

Modal for Medical Policy Terms of Use

 

GDPR Notification Content