| Medical Policy Updates June 2025 |
062025 |
| 140 |
140 Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction |
| 501 |
2024 MPG Schedule |
| 501 |
2025 MPG Schedule |
| 451 |
451 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis |
| 451 |
451 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis |
| 621 |
A Quality Care Dosing Guidelines |
| 186 |
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse |
| 841 |
Adjunctive Techniques for Screening and Surveillance and Risk Classification of Barrett Esophagus and Esophageal Dysplasia |
| 089 |
Adoptive Cell Therapies for Melanoma |
| 455 |
Adoptive Immunotherapy |
| 972 |
Advanced Imaging of the Heart |
| 971 |
Advanced Imaging of the Heart CPT and HCPCS Codes |
| 968 |
Advanced Imaging Radiology |
| 142 |
Air Ambulance Transport |
| 190 |
Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias |
| 155 |
Allogeneic Hematopoietic Cell transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms |
| 328 |
Allogeneic Pancreas Transplant |
| 838 |
Allograft Injection for Degenerative Disc Disease |
| 119 |
Ambulatory Electrocardiograph (AECG) Monitoring |
| 643 |
Amniotic Membrane and Amniotic Fluid |
| 246 |
Ampyra dalfampridine |
| 557 |
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening |
| 536 |
Analysis of Proteomic Patterns for Early Detection of Cancer |
| 021 |
Anti-Migraine Policy |
| 054 |
Anti-Parkinsonism Drugs |
| 673 |
Antigen Leukocyte Antibody Test |
| 013 |
Antihyperlipidemics |
| 027 |
Antisense Oligonucleotide Medications |
| 144 |
Applied Behavior Analysis Service Request Form |
| 091 |
Applied Behavioral Analysis (ABA) |
| 223 |
Aqueous Shunts and Stents for Glaucoma |
| 592 |
Artificial Intervertebral Disc - Lumbar Spine |
| 086 |
Assisted Reproductive Services Infertility Services |
| 694 |
Assisted Reproductive Technology Services Form for Policy Infertility Diagnosis and Treatment |
| 011 |
Asthma and Chronic Obstructive Pulmonary Disease Medication Management |
| 506 |
AudioHealth Library |
| 481 |
Auditory Brainstem Implant |
| 206 |
Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure |
| 231 |
Automated Percutaneous and Percutaneous Discectomy |
| 713 |
Autonomic Nervous System Testing |
| 404 |
Axial Lumbosacral Interbody Fusion |
| 184 |
Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema |
| 621 |
B Quality Care Dosing Guidelines Drug List |
| 018 |
Balloon Dilation of the Eustachian Tube |
| 582 |
Balloon Sinuplasty for Treatment of Chronic Sinusitis |
| 595 |
Baroreflex Stimulation Devices |
| 707 |
Benign Skin Lesions |
| 663 |
Bioengineered Skin and Soft Tissue Substitutes |
| 210 |
Biofeedback as a Treatment of Chronic Pain |
| 308 |
Biofeedback as a Treatment of Fecal Incontinence or Constipation |
| 173 |
Biofeedback as a Treatment of Urinary Incontinence |
| 187 |
Biofeedback for Miscellaneous Indications |
| 152 |
Biofeedback for the Treatment of Headache |
| 261 |
Bioimpedance Devices for the Detection of Lymphedema |
| 336 |
Biomarkers for Diagnosis & Cancer Risk Assessment of Prostate Cancer |
| 101 |
Biventricular Pacemakers - Cardiac Resynchronization Therapy for the Treatment of Heart Failure |
| 740 |
Blepharoplasty Blepharoptosis repair and Brow ptosis repair |
| 097 |
Bone Morphogenetic Protein |
| 549 |
Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover |
| 006 |
Botulinum Toxin Injections |
| 493 |
Breast Duct Endoscopy |
| 284 |
Bronchial Thermoplasty |
| 313 |
Bronchial Valves |
| 503 |
CA-125 |
| 116 |
Cardiac Catheterization and Coronary Angiography |
| 287 |
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting |
| 916 |
Cardiac Rehabilitation in the Outpatient Setting |
| 930 |
Carelon Abdomen and Pelvic Imaging CPT and Diagnoses Codes prn |
| 900 |
Carelon Advanced Imaging Radiology CPT and HCPCS Codes prn |
| 931 |
Carelon Brain Imaging CPT and Diagnoses Codes prn |
| 932 |
Carelon Chest Imaging CPT and Diagnoses Codes prn |
| 933 |
Carelon Extremity Imaging CPT and Diagnoses Codes prn |
| 957 |
Carelon Genetic Testing Management Program CPT and HCPCS Codes |
| 954 |
Carelon Genetic Testing Management Program prn |
| 934 |
Carelon Head and Neck Imaging CPT and Diagnoses Codes prn |
| 939 |
Carelon Medical Benefits Management What's New Page prn |
| 929 |
Carelon Oncologic Imaging CPT, HCPCS and Diagnoses Codes prn |
| 099 |
Carelon Oncology Medication Management Program |
| 935 |
Carelon Spine Imaging CPT and Diagnoses Codes prn |
| 936 |
Carelon Vascular Imaging CPT and Diagnoses Codes prn |
| 219 |
Carotid Stent Placemen |
| 141 |
Catheter Ablation as Treatment for Atrial Fibrillation |
| 122 |
Chelation Therapy |
| 732 |
Chemical Peels |
| 066 |
Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma |
| 942 |
Chimeric Antigen Receptor Therapy for Multiple Myeloma ABECMA (Idecabtagene Vicleucel) |
| 904 |
Chromoendoscopy as an Adjunct to Colonoscopy |
| 000 |
Clinical_Exception_Process_prn |
| 121 |
Closure Devices for Patent Foramen Ovale and Atrial Septal Defects |
| 019 |
CNS Stimulants and Psychotherapeutic Agents |
| 478 |
Cochlear Implant |
| 178 |
Complementary Medicine |
| 662 |
Composite Tissue Allotransplantation of the Hand and Face |
| 705 |
Compound Medications Exclusion Drug List |
| 704 |
Compound Medications Inclusion Drug List |
| 579 |
Compounded Medications |
| 594 |
Computer-Assisted Navigation Orthopedic Procedure |
| 618 |
Confocal Laser Endomicroscopy |
| 107 |
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems |
| 407 |
Continuous Passive Motion in the Home Setting |
| 510 |
Cooling Devices Used in the Outpatient Setting |
| 905 |
Corneal Collagen Cross-linking |
| 002 |
Cox II Inhibitor Drugs |
| 362 |
Cranial Electrotherapy Stimulation and Auricular Electrostimulation |
| 260 |
Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone |
| 843 |
Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis |
| 633 |
Cryosurgical Ablation of Primary or Metastatic Liver Tumors |
| 271 |
Decompression of the Intervertebral Disc Using Laser Energy - or Radiofrequency Coblation - Nucleoplasty |
| 473 |
Deep Brain Stimulation |
| 000 |
Definition of Med Nec Inv Not Med Nec prn |
| 463 |
Dermatologic Applications of Photodynamic Therapy |
| 041 |
Diabetes Step Therapy |
| 264 |
Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology |
| 352 |
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis |
| 320 |
Diagnosis and Treatment of Sacroiliac Joint Pain |
| 139 |
Diagnostic Laboratory Services |
| 593 |
Diaphragmatic Phrenic Nerve and Diaphragm Pacing Systems |
| 175 |
Digital Health Technologies Diagnostic Applications |
| 090 |
Digital Health Technologies Therapeutic Applications |
| 947 |
Digital Health Therapies for Attention Deficit |
| 411 |
Directory of Documents |
| 918 |
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography |
| 049 |
Drug Management & Retail Pharmacy Prior Authorization Policy |
| 251 |
Drug Management and Prior Authorization |
| 674 |
Drug Testing in Pain Management and Substance Use Disorder Treatment |
| 408 |
Drugs for Cystic Fibrosis |
| 092 |
Drugs for Macular Degeneration and Diabetic Eye Disease |
| 572 |
Drugs for Weight Loss |
| 164 |
Dry Hydrotherapy for chronic pain conditions |
| 792 |
Dry Needling and Trigger Point Injections for Myofascial Pain |
| 842 |
Durable Medical Equipment DME |
| 405 |
Dynamic Low-Load Prolonged Duration Stretch Devices |
| 263 |
Dynamic Posturography |
| 195 |
Dynamic Spinal Visualization and Vertebral Motion Analysis |
| 023 |
E Form medication prior auth instruction |
| 499 |
Electrical Bone Growth Stimulation of the Appendicular Skeleton |
| 157 |
Electrical Stimulation Devices for Psychiatric and Neurological Conditions |
| 302 |
Electrical Stimulation for the Treatment of Arthritis |
| 498 |
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures |
| 203 |
Electromagnetic Navigation Bronchoscopy |
| 701 |
Electromyography and Nerve Conduction Studies |
| 655 |
Electrostimulation and Electromagnetic Therapy for Treating Wounds |
| 009 |
Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm |
| 928 |
Elzonris Prior Authorization Request Form MP 009 |
| 648 |
End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema |
| 715 |
Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer |
| 218 |
Endoscopic Radiofrequency Ablation or Cryoablation for Barretts Esophagus |
| 098 |
Endovascular Grafts for Abdominal Aortic Aneurysms |
| 323 |
Endovascular Procedures for Intracranial Arterial Disease - Atherosclerosis and Aneurysms |
| 233 |
Endovascular Stent Grafts for Disorders of the Thoracic Aorta |
| 649 |
Enhanced External Counterpulsation - EECP - for Chronic Stable Angina or Congestive Heart Failure |
| 162 |
Entyvio ( Vedolizumab ) Policy |
| 492 |
Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management - Ductal Lavage and Suction Collection Systems |
| 262 |
Erythropoietin, Recombinant Human and Hypoxia-Inducible Factor Inhibitors |
| 087 |
Esketamine Nasal Spray (SpravatoTM) and Intravenous Ketamine for Mental Health Conditions |
| 069 |
Esophageal pH Monitoring |
| 581 |
Evaluation of Biomarkers for Alzheimer Disease |
| 726 |
Extracorporeal Membrane Oxygenation |
| 248 |
Extracorporeal Photopheresis |
| 081 |
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions |
| 613 |
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome |
| 174 |
Facet Arthroplasty |
| 360 |
Factor and Non-Factor Anti-Hemophilic Drugs |
| 360 |
Factor and Non-Factor Anti-Hemophilic Drugs |
| 556 |
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis |
| 329 |
Fecal Calprotectin Testing |
| 682 |
Fecal Microbiota Transplantation |
| 113 |
Fentanyl, oral-transmucosal |
| 341 |
Flow Cytometry for Cell Analysis |
| 733 |
Focal Treatments for Prostate Cancer |
| 039 |
Fractional Carbon Dioxide (CO2) Laser Ablation Treatment of Hypertrophic Scars or Keloids for Functional Improvement |
| 201 |
Functional Neuromuscular Electrical Stimulation |
| 371 |
Gas Permeable Scleral Contact Lens pdf.pdf |
| 636 |
Gastric Electrical Stimulation |
| 189 |
Gender Affirming Services (Transgender Services) |
| 159 |
Gene Therapies for Bladder Cancer |
| 022 |
Gene Therapies for Duchenne Muscular Dystrophy |
| 168 |
Gene Therapies for Hemophilia A or B |
| 106 |
Gene Therapies for Metaloleukodystrophy |
| 050 |
Gene Therapies for Sickle Cell Disease |
| 215 |
Gene Therapies for Thalassemia Zynteglo Betibeglogene automeucel |
| 241 |
Gene Therapy for Cerebral Adrenoleukodystrophy SKYSONA |
| 911 |
Gene Therapy for Inherited Retinal Dystrophy Luxturna |
| 056 |
Glucagon-like Peptide-1 (GLP-1) Receptor Agonists and Related Drugs for the Treatment of Type 2 Diabetes |
| 146 |
Ground Ambulance |
| 257 |
Growth Hormone and Insulin-like Growth Factor |
| 546 |
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery |
| 063 |
Heart Failure and Hypertrophic Cardiomyopathy (HCM) Policy |
| 269 |
Heart Lung Transplant |
| 197 |
Heart Transplant |
| 076 |
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia |
| 150 |
Hematopoietic Cell Transplantation for Acute Myeloid Leukemia |
| 192 |
Hematopoietic Cell Transplantation for Autoimmune Diseases |
| 074 |
Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma |
| 212 |
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia |
| 205 |
Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma |
| 204 |
Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer |
| 207 |
Hematopoietic Cell Transplantation for Hodgkin Lymphoma |
| 191 |
Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults |
| 143 |
Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas |
| 075 |
Hematopoietic Cell Transplantation for Plasma Cell Dyscracias, Including Multiple Myeloma and POEMS Syndrome |
| 181 |
Hematopoietic Cell Transplantation for Primary Amyloidosis |
| 208 |
Hematopoietic Cell Transplantation for Solid Tumors of Childhood |
| 247 |
Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors |
| 322 |
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia |
| 697 |
HETLIOZ tasimelteon |
| 104 |
High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell's Palsy |
| 032 |
High-Sensitivity C-Reactive Protein |
| 046 |
Hip Resurfacing |
| 224 |
Home Cardiorespiratory Monitoring |
| 430 |
Home Infusion Therapy Prior Authorization Form |
| 296 |
Home Total Parenteral Nutrition TPN |
| 016 |
Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease |
| 653 |
Hyperbaric Oxygen Therapy |
| 048 |
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies |
| 131 |
Hypoactive Sexual Desire Disorder (HSDD) Policy |
| 555 |
Identification of Microorganisms Using Nucleic Acid Probe |
| 240 |
Image-Guided Minimally Invasive Decompression for Spinal Stenosis |
| 182 |
Immune Cell Function Assay in Solid Organ Transplantation |
| 004 |
Immune Modulating Drugs |
| 310 |
Immunoglobulins Policy |
| 010 |
Immunomodulators for Skin Conditions |
| 479 |
Implantable Bone-Conduction and Bone-Anchored Hearing Aids |
| 070 |
Implantable Cardioverter Defibrillator |
| 103 |
Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions |
| 103 |
Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions |
| 521 |
In Vivo Analysis of Colorectal Polyps |
| 000 |
Indemnity_and_PPO_Guidelines_prn |
| 440 |
Influenza Drugs Tamiflu and Relenza |
| 100 |
Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure in Neonates |
| 017 |
Injectable Asthma Medications |
| 471 |
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence |
| 071 |
Injectable Specialty Medication Coverage |
| 427 |
Injections for Osteoarthritis |
| 332 |
Insulin Delivery Devices |
| 532 |
Insulin Potentiation Therapy |
| 509 |
Interferential Stimulation for Treatment of Pain |
| 052 |
Interferons Alpha and Gamma |
| 220 |
InterQual Musculoskeletal Services Management |
| 221 |
InterQual Musculoskeletal Services Management CPT and HCPCS Codes |
| 584 |
Interspinous and Interlaminar Stabilization-Distraction Devices - Spacers |
| 436 |
Interspinous Fixation - Fusion Devices |
| 073 |
Intracellular Micronutrient Analysis |
| 610 |
Intraocular Radiation Therapy for Age-Related Macular Degeneration |
| 211 |
Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring) |
| 485 |
Intraosseous Basivertebral Nerve Ablation |
| 291 |
Intravenous Anesthetics for the Treatment of Chronic Pain |
| 171 |
Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease |
| 272 |
Intravitreal and Punctum Corticosteroid Implants |
| 188 |
Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung |
| 324 |
Islet Transplantation |
| 631 |
Isolated Small Bowel Transplant |
| 000 |
January 26 2021 Neurology and Neurosurgery Medical Policy Group Agenda |
| 196 |
Kidney Transplant |
| 165 |
Laboratory Testing Investigational Services |
| 530 |
Laboratory Tests Post Transplant and for Heart Failure |
| 244 |
Laparoscopic andTranscervical Techniques for the Myolysis of Uterine Fibroids |
| 948 |
Laser Interstitial Thermal Therapy for Neurological Conditions |
| 461 |
Laser Treatment of Active Acne |
| 562 |
Laser Treatment of Onychomycosis |
| 038 |
Leadless Cardiac Pacemakers |
| 334 |
Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation |
| 589 |
Leukocyte Histamine Release Test |
| 465 |
Lipid Apheresis |
| 198 |
Liver Transplant and Combined Liver-Kidney Transplant |
| 177 |
Low-Dose Radiotherapy for Non-Oncologic Indications |
| 522 |
Low-Level Laser Therapy |
| 015 |
Lung and Lobar Lung Transplant |
| 364 |
Lung Volume Reduction Surgery for Severe Emphysema |
| 000 |
Managed_Care_Guidelines_prn |
| 483 |
Manipulation under Anesthesia |
| 365 |
Manual and Power Operated Wheelchairs |
| 434 |
Massachusetts Standard Form for Medication Prior Authorization Requests |
| 163 |
Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes |
| 524 |
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders |
| 917 |
Measurement of Serum Antibodies to Selected Biologic Agents |
| 379 |
Medical and Surgical Management of Obesity including Anorexiants |
| 034 |
Medical Benefit Prior Authorization Medication List |
| 999 |
Medical Policy Updates |
| 350 |
Medical Technology Assessment Guidelines |
| 400 |
Medical Technology Assessment NonCovered Services |
| 000 |
Medical_Policy_Terms_of_Use_prn |
| 000 |
Medical_Technology_Assessment_Guidelines_prn |
| 923 |
Medicare Advantage High Technology Radiology & Sleep Disorder Management Redirect |
| 132 |
Medicare Advantage Management |
| 020 |
Medicare Advantage Part B Step Therapy |
| 125 |
Medicare Advantage Part B Utilization Management |
| 442 |
Medicare Part D Coverage Determination Request Form |
| 083 |
Medications for Sickle Cell and Beta Thalassemia |
| 453 |
Melanoma Vaccines |
| 274 |
Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction |
| 840 |
Methotrexate Step Therapy |
| 133 |
Microprocessor Controlled Prostheses for the Lower Limb |
| 912 |
Microwave Tumor Ablation |
| 450 |
Mineral Density Studies |
| 744 |
Minimally Invasive and surgical treatment options for Benign Prostatic Hyperplasia |
| 029 |
Molecular Testing in the Management of Pulmonary Nodules |
| 154 |
Monitored Anesthesia Care - MAC |
| 946 |
Monoclonal Antibodies for Treatment of Alzheimer's Disease |
| 243 |
MRI-Guided Focused Ultrasound - MRgFUS |
| 677 |
Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis |
| 124 |
Multicancer Early Detection Testing |
| 249 |
Multimarker Serum Testing Related to Ovarian Cancer |
| 839 |
Multiple Sclerosis Prior Auth Policy |
| 748 |
Multispectral Digital Skin Lesion Analysis |
| 711 |
Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis |
| 062 |
Mupirocin Step Policy |
| 112 |
Myocardial Strain Imaging |
| 576 |
Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure |
| 227 |
Myoelectric Prosthetic and Components for the Upper Limb |
| 543 |
Negative Pressure Wound Therapy in the Outpatient Setting |
| 393 |
Nerve Fiber Density Measurement |
| 590 |
Nerve Graft in Association with Radical Prostatectomy |
| 914 |
Neural Therapy |
| 151 |
Neuropsychological and Psychological Testing |
| 005 |
New Drug Approval Program |
| 462 |
Non pharmacologic Treatment of Rosacea |
| 691 |
Non-Invasive Vascular Studies - Duplex Scans |
| 657 |
Noncontact Ultrasound Treatment for Wounds |
| 433 |
Noncovered Drug List |
| 921 |
Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease |
| 123 |
Nononcologic Uses of Rituximab |
| 283 |
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease |
| 745 |
Nutrient - Nutritional Panel Testing |
| 007 |
Obstetrical Ultrasound and Ultrasound for Family Planning |
| 237 |
Occipital Nerve Stimulation |
| 028 |
Omidubicel as Adjunct Treatment for Hematologic Malignancies |
| 454 |
Oncologic Applications of Photodynamic Therapy, Including Barretts Esophagus |
| 409 |
Oncology Drugs |
| 356 |
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation - Maze and Related Procedures |
| 346 |
Ophthalmic Prostaglandins |
| 053 |
Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma |
| 102 |
Opioid Medication Management |
| 915 |
Optical Coherence Tomography for Imaging of Coronary Arteries |
| 084 |
Optical Coherence Tomography of the Anterior Eye Segment |
| 179 |
Orthognathic Surgery |
| 737 |
Orthopedic Applications of Platelet-Rich Plasma |
| 254 |
Orthopedic Applications of Stem Cell Therapy |
| 550 |
Orthotics for Progressive Scoliosis |
| 120 |
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions |
| 369 |
Ostomy Supplies |
| 660 |
Outpatient Cognitive Rehabilitation |
| 158 |
Outpatient Pediatric Pain Rehabilitation Centers |
| 072 |
Outpatient Prior Authorization Code List |
| 423 |
Outpatient Psychotherapy |
| 136 |
Outpatient Pulmonary Rehabilitation |
| 266 |
Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome |
| 170 |
Overactive Bladder Medications |
| 517 |
Paraspinal Surface Electromyography - SEMG - to Evaluate and Monitor Back Pain |
| 045 |
Pathogen Panel Testing |
| 721 |
Patient-Actuated End Range Motion Stretching Devices |
| 706 |
Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty |
| 470 |
Pelvic Floor Stimulation as a Treatment of Urinary Incontinence and Fecal Incontinence |
| 583 |
Percutaneous and Subcutaneous Tibial Nerve Stimulation |
| 117 |
Percutaneous Coronary Intervention |
| 922 |
Percutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain Disorders |
| 172 |
Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy and Restorative Neurostimulation Therapy |
| 482 |
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation |
| 161 |
Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease |
| 513 |
Peripheral Subcutaneous Field Stimulation |
| 344 |
Pharmacy Hepatitis C Medication Management |
| 051 |
Pharmacy Specialty List |
| 033 |
Pharmacy-MED_UM_Policy_SP |
| 607 |
Photocoagulation of Macular Drusen |
| 599 |
Photodynamic Therapy for Choroidal Neovascularization |
| 059 |
Phototherapy PUVA UV-B and Targeted Phototherapy |
| 955 |
Phrenic Nerve Stimulation for Central Sleep Apnea |
| 466 |
Plasma Exchange |
| 528 |
Plugs for Fistula Repair |
| 354 |
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers |
| 541 |
Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis |
| 718 |
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities |
| 047 |
Preauthorization Request Form for 379 Surgical Management of Obesity Policy |
| 926 |
Preauthorization Request Form for Gene Therapy for Inherited Retinal Dystrophy |
| 057 |
Pregabalin (Lyrica and Lyrica CR) |
| 088 |
Preimplantation Genetic Testing |
| 413 |
Preventive Screening Tests |
| 148 |
Prior Authorization Request Form for Zulresso (Brexanolone) for the Treatment of Postpartum Depression MP 147 |
| 067 |
Prior Authorization Request for MP 028 Omidubicel as Adjunct Treatment for Hematologic Malignancies |
| 096 |
Prior Authorization Request Form for Adoptive Cell Therapies for Melanoma MP 089 |
| 193 |
Prior Authorization Request Form for Adstiladrin (nadofaragene firadenovec-vncg) |
| 942 |
Prior Authorization Request Form for CAR T-Cell Therapy Services for Multiple Myeloma ABECMA (Idecabtagene Vicleucel) |
| 945 |
Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (Brexucabtagene Autoleucel) |
| 925 |
Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (tisagenlecleucel) MP 066 |
| 944 |
Prior Authorization Request Form for CAR T-Cell Therapy Services for Follicular Lymphoma (Axicabtagene Ciloleucel) |
| 940 |
Prior Authorization Request Form for CAR T-Cell Therapy Services for Mantle Cell Lymphoma (Brexucabtagene Autoleucel) MP 066 |
| 941 |
Prior Authorization Request Form for CAR T-Cell Therapy Services for Non-Hodgkin Lymphoma (Lisocabtagene Maraleucel) |
| 924 |
Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse Large B-cell Lymphoma |
| 844 |
Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse Large B-cell Lymphoma (Tisagenlecleucel) MP 066 |
| 846 |
Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Follicular Lymphoma (tisagenlecleucel) MP 066 |
| 927 |
Prior Authorization Request Form for Diagnosis and Treatment of Sacroiliac Joint Pain MP 320 |
| 025 |
Prior Authorization Request Form for Duchenne Muscular Dystrophy |
| 902 |
Prior Authorization Request Form for Electrolysis for Gender Affirming Services MP 189 |
| 094 |
Prior Authorization Request Form for Esketamine Nasal Spray and Intravenous Ketamine for Mental Health Conditions |
| 901 |
Prior Authorization Request Form for Gender Affirming Services (Transgender Services) MP 189 |
| 166 |
Prior Authorization Request Form for Gene Therapies for Hemophilia A Roctavian (Valoctocogene roxaparvovec-rvox) |
| 169 |
Prior Authorization Request Form for Gene Therapies for Hemophilia B |
| 126 |
Prior Authorization Request Form for Gene Therapies for Hemophilia B Beqvez® (Fidanacogene eleparvovec-dzkt) |
| 109 |
Prior Authorization Request Form for Gene Therapies for Metachromatic Leukodystrophy |
| 055 |
Prior Authorization Request Form for Gene Therapies for Sickle Cell Disease |
| 217 |
Prior Authorization Request Form for Gene Therapies for Thalassemia Casgevy Autotemcel |
| 216 |
Prior Authorization Request Form for Gene Therapies for Thalassemia Zynteglo Betibeglogene automeucel |
| 242 |
Prior Authorization Request Form for Gene Therapy for Cerebral Adrenoleukodystrophy SKYSONA |
| 486 |
Prior Authorization Request Form for Intraosseus Basivertebral Nerve Ablation Intracept System MP 485 |
| 079 |
Prior Authorization Request Form for Lyfgenia |
| 949 |
Prior Authorization Request Form for Monoclonal Antibodies for Treatment of Alzheimer's Disease - Lecanemab (Leqembi) MP 946 |
| 973 |
Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb MP 227 |
| 160 |
Prior Authorization Request Form for Scenesse MP 077 |
| 956 |
Prior Authorization Request Form for Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease MP 920 |
| 129 |
Prior Authorization Request Form for Treatment of Varicose Veins Venous Insufficiency |
| 085 |
Prior Authorization Request Form for Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy MP 008 |
| 183 |
Prolotherapy |
| 709 |
Proteomic Testing for Systemic Therapy in Non-Small-Cell Lung Cancer |
| 030 |
Proton Pump Inhibitors |
| 937 |
Quality Care Cancer Program (Radiation Oncology) |
| 938 |
Quality Care Cancer Program (Radiation Oncology) CPT and HCPCS Codes |
| 554 |
Quantitative Electroencephalography as a Diagnostic Aid for Attention-DeficitHyperactivity Disorder, Cognitive Impairment, or Autism Spectrum |
| 258 |
Quantitative Sensory Testing |
| 292 |
Radioembolization for Primary and Metastatic Tumors of the Liver |
| 259 |
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors |
| 794 |
Radiofrequency Ablation of Peripheral Nerves to Treat Pain |
| 286 |
Radiofrequency Ablation of Primary or Metastatic Liver Tumors |
| 919 |
Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension |
| 080 |
Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions |
| 428 |
Reconstructive Breast Surgery-Management of Breast Implants |
| 703 |
Reduction Mammaplasty for Breast-Related Symptoms |
| 145 |
Remote Electrical Neuromodulation for Migraines |
| 064 |
Repository Corticotropin Injection (H.P Acthar Gel).pdf |
| 716 |
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy |
| 586 |
Rhinomanometry and Acoustic or Optical Rhinometry |
| 385 |
Routine Foot Care and Debridement of Toenails |
| 422 |
RSV Immunoprophylaxis |
| 153 |
Sacral Nerve Neuromodulation-Stimulation |
| 307 |
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer |
| 077 |
Scenesse afamelanotide for the treatment of Erythropoietic protoporphyria |
| 494 |
Scintimammography, Breast-Specific Gamma Imaging, and Molecular Breast Imaging |
| 480 |
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid |
| 659 |
Sensory Integration Therapy |
| 138 |
Serological Diagnosis of Celiac Disease |
| 551 |
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease |
| 290 |
Serum Biomarker Human Epididymis Protein 4 - HE4 |
| 702 |
Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases |
| 538 |
Serum Tumor Markers for Breast and Gastrointestinal Malignancies |
| 156 |
Shoulder Resurfacing |
| 134 |
Signal-Averaged Electrocardiography - SAECG |
| 118 |
Single Chamber and Dual Chamber Permanent Cardiac Pacemakers |
| 969 |
Sleep Disorder Management |
| 970 |
Sleep Disorder Management CPT and HCPCS Codes |
| 632 |
Small Bowel, Liver, and Multivisceral Transplant |
| 093 |
Soliris, Ultomiris, Complement 3 Glomerulopathy (C3G), Myasthenia Gravis, Paroxysmal nocturnal hemoglobinuria (PNH), and Neuromyelitis Optica Policy |
| 093 |
Soliris, Ultomiris, Complement 3 Glomerulopathy (C3G), Myasthenia Gravis, Paroxysmal nocturnal hemoglobinuria (PNH), and Neuromyelitis Optica Policy |
| 304 |
Special Foods |
| 026 |
Sphenopalatine Ganglion Block for Headache |
| 044 |
Spinal Muscular Atrophy (SMA) Medications |
| 199 |
Stationary Ultrasonic Diathermy Devices |
| 348 |
Stem-cell Therapy for Peripheral Arterial Disease |
| 800 |
Steroid-Eluting Sinus Stents |
| 681 |
Sublingual Immunotherapy with Allergen-specific Extracts - SLIT |
| 299 |
Subtalar Arthroereisis |
| 043 |
Suction Lipectomy for Lipedema |
| 105 |
Supportive Care Treatments for Patients with Cancer |
| 609 |
Suprachoroidal Delivery of Pharmacologic Agents |
| 068 |
surgeries |
| 695 |
Surgery for Groin Pain in Athletes |
| 037 |
Surgical and Debulking Treatments for Lymphedema |
| 661 |
Surgical and Non-surgical Treatment of Gynecomastia |
| 920 |
Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease |
| 801 |
Surgical Deactivation of Headache Trigger Sites |
| 570 |
Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea |
| 130 |
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome |
| 544 |
Surgical Ventricular Restoration |
| 031 |
Suture Button Suspensionplasty Fixation System for Thumb Carpometacarpal Osteoarthritis |
| 250 |
Systems Pathology in Prostate Cancer |
| 035 |
Temporomandibular Joint Disorder |
| 321 |
Threshold Electrical Stimulation as a Treatment of Motor Disorders |
| 426 |
Topical Ocular Hydrating Agents |
| 345 |
Topical Testosterone |
| 280 |
Total Artificial Hearts and Implantable Ventricular Assist Devices |
| 200 |
Transanal Endoscopic Microsurgery |
| 392 |
Transcatheter Aortic-Valve Implantation for Aortic Stenosis |
| 634 |
Transcatheter Arterial Chemoembolization - TACE - to Treat Primary or Metastatic Liver Malignancies |
| 692 |
Transcatheter Mitral Valve Repair or Replacement |
| 403 |
Transcatheter Pulmonary Valve Implantation |
| 297 |
Transcranial Magnetic Stimulation as a Treatment of Depression |
| 003 |
Transcutaneous Electrical Nerve Stimulation |
| 114 |
Transesophageal Echocardiography (TEE) |
| 600 |
Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization |
| 115 |
Transthoracic Echocardiography (TTE) |
| 108 |
Treatment of Congenital Athymia |
| 406 |
Treatment of Hyperhidrosis |
| 267 |
Treatment of Tinnitus |
| 238 |
Treatment of Varicose Veins and Venous Insufficiency |
| 604 |
Trigger Point and Tender Point Injections |
| 167 |
Tumor Markers for diagnosis and management of cancer |
| 303 |
Ultrasonographic Evaluation of Skin Lesions |
| 547 |
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis |
| 497 |
Ultrasound Accelerated Fracture Healing Device |
| 445 |
Ultrasound for the Evaluation of Paranasal Sinuses |
| 742 |
Urinary Metabolite Tests for Adherence to Direct-Acting Antiviral |
| 370 |
Urological Supplies |
| 060 |
Uterus Transplantation for Absolute Uterine Factor Infertility |
| 474 |
Vagus Nerve Stimulation |
| 014 |
Veozah Step Policy |
| 603 |
Vertebral Axial Decompression |
| 449 |
Vertebral Fracture Assessment with Densitometry or Biomechanical Computed Tomography |
| 305 |
Vertical Expandable Prosthetic Titanium Rib |
| 024 |
Vestibular Function Testing |
| 372 |
Viscocanalostomy and Canaloplasty |
| 675 |
Vision Services |
| 061 |
Vitamin B12 Testing |
| 746 |
Vitamin D Assay Testing |
| 042 |
Wearable Cardioverter Defibrillators |
| 577 |
Whole Body Dual X-Ray Absorptiometry to Determine Body Composition |
| 447 |
Whole-Body Computed Tomography Scan as a Screening Test |
| 185 |
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders |
| 306 |
Wireless Pressure Sensors in Endovascular Aneurysm Repair |
| 008 |
Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy |
| 147 |
ZulressoTM (Brexanolone) for the Treatment of Post-Partum Depression |