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 1– 50 of 360 Results
Title Last Updated Category
Reduction Mammaplasty (Mammoplasty) Open a PDF 7.01.39 2026-10-06 Cosmetic / Reconstructive Surgery
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)
Orthopedic Joint Procedures of the Shoulder 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 7.01.125 2026-10-05 Bone & Joints (Orthopedic)
Intraosseous Basivertebral Nerve Ablation for Child Health Plus (CHP), and Essential Plan (EP) Members (Effective 2027-01-01) Open a PDF 7.01.124 2026-10-05 Bone & Joints (Orthopedic)
Orthopedic Joint Procedures of the Knee 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 7.01.123 2026-10-05 Bone & Joints (Orthopedic)
Interventional Pain Management 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 7.01.122 2026-10-05 Bone & Joints (Orthopedic)
Orthopedic Joint Procedures of the Hip 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 7.01.121 2026-10-05 Bone & Joints (Orthopedic)
Left Atrial Appendage Closure Devices Open a PDF 7.01.92 2026-09-21 Heart & Blood Vessels (Cardiovascular)
Injectable Fillers for Dermal and Laryngeal Conditions Open a PDF 7.01.119 2026-09-21 Miscellaneous
Cosmetic and Reconstructive Procedures Open a PDF 7.01.11 2026-09-21 Cosmetic / Reconstructive Surgery
Radiopharmaceuticals for the Treatment of Cancer Open a PDF 6.01.44 2026-09-21 Cancer Treatment (Oncology)
Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome Open a PDF 4.01.10 2026-09-21 Women's Health (Obstetrics & Gynecology)
Genetic Testing for Thoracic Aortic Aneurysms/ Dissections and Connective Tissue Related Disorders Open a PDF 2.02.61 2026-09-21 Genetic Disease (Inherited Disease)
Laboratory Testing for the Screening and Management of Prostate Cancer Open a PDF 2.02.48 2026-09-21 Genetic Disease (Inherited Disease)
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Open a PDF 2.02.46 2026-09-21 Genetic Disease (Inherited Disease)
Inflammatory Markers of Coronary Artery Disease Risk Open a PDF 2.02.15 2026-09-21 Lab Tests (pathology)
Colorectal Cancer Screening and Surveillance Open a PDF 2.01.51 2026-09-21 Digestive System (Gastroenterology)
Fecal Microbiota Transplantation Open a PDF 2.01.48 2026-09-21 Digestive System (Gastroenterology)
Clinical Trials Open a PDF 11.01.10 2026-09-21 Miscellaneous
Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis Open a PDF 1.01.51 2026-09-21 Durable Medical Equipment & Supplies
Negative Pressure Wound Therapy (Vacuum-Assisted Closure) Open a PDF 01.01.38 2026-09-21 Skin (Dermatology)
Transcranial Magnetic Stimulation and Cranial Electrotherapy Stimulation Open a PDF 3.01.09 2026-09-17 Behavioral Health (Psychiatry/Psychology)
Amniotic Membrane Grafting/Transplantation (AMG/AMT) for Ophthalmologic Conditions (Effective 2026-12-15) Open a PDF 9.01.20 2026-09-15 Eyes (Ophthalmology)
Patient Lifts (Effective 2026-11-16) Open a PDF 1.01.08 2026-09-14 Home Care
Patient Lifts (e.g., Hoyer, Saralift, Seat Lift, Chair Mechanisms, and Ceiling Lifts) Open a PDF 1.01.08 2026-09-14 Home Care
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds Open a PDF 2.01.31 2026-09-01 Bone & Joints (Orthopedic)
Non-Invasive Prenatal Testing Open a PDF 2.02.25 2026-08-25 Lab Tests (pathology)
Medical Response to Contamination from Terrorist Attacks Open a PDF 11.01.09 2026-08-25 Miscellaneous
Disability Determination For Extension of Benefits After Coverage Termination Open a PDF 10.01.11 2026-08-25 Miscellaneous
Second Medical and Surgical Opinions Open a PDF 10.01.10 2026-08-25 Miscellaneous
Breast Reconstruction Surgery and Prophylactic Breast Cancer Risk-Reducing Mastectomy Open a PDF 10.01.01 2026-08-25 Cosmetic / Reconstructive Surgery
Thermal Ablation for Solid Tumor Treatment Open a PDF 7.01.111 2026-08-25 Cancer Treatment (Oncology)
Balloon Sinus Ostial Dilation for Treatment of Chronic Rhinosinusitis (i.e., Balloon Sinuplasty) Open a PDF 7.01.85 2026-08-25 Ear, Nose & Throat (Otorhinolaryngology)
Bioengineered Tissue Products for Wound Treatment and Surgical Interventions Open a PDF 7.01.35 2026-08-25 Skin (Dermatology)
Vagus Nerve Stimulation and Vagus Nerve Blocking Therapy Open a PDF 7.01.05 2026-08-25 Nervous Systems (Neurology)
Focal Therapies for Prostate Cancer Treatment Open a PDF 7.01.01 2026-08-25 Urinary System (Genitourinary)
Proton Beam Radiation Therapy Open a PDF 6.01.11 2026-08-25 Radiation Treatment
Bone Densitometry/Bone Density Studies Open a PDF 6.01.05 2026-08-25 Radiology (x-rays) & Imaging
Gender Affirming Behavioral Health and Medical Services Open a PDF 3.01.22 2026-08-25 Miscellaneous
Partial Hospitalization for Substance Use Disorders Open a PDF 3.01.18 2026-08-25 Behavioral Health (Psychiatry/Psychology)
Measurable Residual Disease (MRD) Assessment Testing Open a PDF 2.02.54 2026-08-25 Lab Tests (pathology)
Wheelchairs and Power Operated Vehicles (POVs) Open a PDF 1.01.16 2026-08-25 Durable Medical Equipment & Supplies
Augmentative and Alternative Communication Systems (e.g., Speech-generating Devices) Open a PDF 1.01.03 2026-08-25 Durable Medical Equipment & Supplies
Durable Medical Equipment (DME) and Devices, Standard and Non-Standard Open a PDF 1.01.00 2026-08-25 Durable Medical Equipment & Supplies
Specialized Neuromodulation for Specific Conditions Open a PDF 1.01.62 2026-08-24 Durable Medical Equipment & Supplies
Experimental or Investigational Services Open a PDF 11.01.03 2026-08-07 Miscellaneous
Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) Open a PDF 7.01.104 2026-08-04 Urinary System (Genitourinary)
Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Services Open a PDF 7.03.01 2026-07-31 Anesthesiology
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
Showing 1– 50 of 360 Results

Modal for Medical Policy Terms of Use

 

GDPR Notification Content