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 301– 340 of 340 Results
Title Last Updated Category
Second Medical and Surgical Opinions Open a PDF 10.01.10 2026-08-25 Miscellaneous
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease Open a PDF 2.02.19 2025-11-25 Lab Tests (pathology)
Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) (Effective 2026-10-15) Open a PDF 7.01.95 2026-07-15 Bone & Joints (Orthopedic)
Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) Open a PDF 7.01.95 2025-07-15 Bone & Joints (Orthopedic)
Sinus Excision/Destruction, Implants, and Repair Open a PDF 7.01.99 2025-12-23 Ear, Nose & Throat (Otorhinolaryngology)
Skilled Nursing Facility Care / Level of Care Criteria Open a PDF 11.01.21 2026-07-21 Miscellaneous
Sleep Studies Open a PDF 2.01.28 2026-01-27 Sleep Medicine
Small Bowel and Multivisceral Transplants in Adults and Children Open a PDF 7.02.05 2026-03-24 Transplants
Specialized Neuromodulation for Specific Conditions Open a PDF 1.01.62 2026-08-24 Durable Medical Equipment & Supplies
Specialty Enclosure Bed Systems Open a PDF 1.01.56 2026-02-13 Durable Medical Equipment & Supplies
Spinal Cord Stimulation / Dorsal Column Stimulation (Effective 2026-10-15) Open a PDF 7.01.51 2026-07-15 Bone & Joints (Orthopedic)
Spinal Cord Stimulation / Dorsal Column Stimulation Open a PDF 7.01.51 2025-07-11 Bone & Joints (Orthopedic)
Spine Procedures for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members (Effective 2027-01-01) Open a PDF 7.01.126 2026-10-05 Bone & Joints (Orthopedic)
Standing Devices and Gait Trainers Open a PDF 1.01.46 2026-02-23 Durable Medical Equipment & Supplies
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Open a PDF 6.01.12 2025-11-14 Radiation Treatment
Surgical Management of Sleep Disorders Open a PDF 7.01.41 2026-01-27 Sleep Medicine
Temporomandibular Joint Disorders (TMJD) Open a PDF 11.01.17 2026-02-13 Bone & Joints (Orthopedic)
Testing for the Use of Biologic Therapeutics for the Treatment of Inflammatory Disorders Open a PDF 2.02.47 2025-11-25 Lab Tests (pathology)
Therapies (Speech, Physical and Occupational) Open a PDF 8.01.24 2025-11-25 Therapy & Rehabilitation
Thermal Ablation for Solid Tumor Treatment Open a PDF 7.01.111 2026-08-25 Cancer Treatment (Oncology)
Tibial Nerve Stimulation (TNS) for Voiding Dysfunction Open a PDF 8.01.22 2026-04-20 Nervous Systems (Neurology)
Total Parenteral Nutrition (TPN) or Hyperalimentation Open a PDF 11.01.04 2026-02-23 Food (Nutrition)
Transarterial Radioembolization (TARE) for Hepatic Tumors Open a PDF 7.01.69 2026-02-23 Radiation Treatment
Transcatheter Heart Valve Procedures Open a PDF 7.01.109 2026-05-27 Heart & Blood Vessels (Cardiovascular)
Transcranial Magnetic Stimulation and Cranial Electrotherapy Stimulation Open a PDF 3.01.09 2026-09-17 Behavioral Health (Psychiatry/Psychology)
Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.45 2026-03-24 Digestive System (Gastroenterology)
Treatment of Gambling Disorder and Other Repetitive Behaviors Open a PDF 3.01.19 2026-02-23 Behavioral Health (Psychiatry/Psychology)
Tumor-Treatment Fields Therapy Open a PDF 6.01.45 2026-04-20 Cancer Treatment (Oncology)
Urinary Tumor Markers for Bladder and Urothelial Cancers Open a PDF 2.02.12 2026-07-21 Lab Tests (pathology)
Urine Drug Testing Open a PDF 2.02.50 2025-12-29 Lab Tests (pathology)
Showing 301– 340 of 340 Results

Modal for Medical Policy Terms of Use

 

GDPR Notification Content