Policies & Procedures

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Medical Policies

Air Ambulance Transportation

Payment Policies

AlloMap Molecular Expression Test

Autism Spectrum Disorders


Medical Policies

Bariatric Surgery

Breast Reduction and Mastectomy for Gynecomastia

Payment Policies

Bladder Cancer Biomarker Tests


Breast Pumps

Breast Reconstruction Procedures and External Breast Prosthesis


Medical Policies

Cardiac Defibrillator Subcutaneous Implantable

Chiropractic Services and Adjunctive Procedures (Children under 13 years of age)

Chromosomal Microarray

Clinical Trials- Coverage of Routine Care Costs

Cochlear Implants

Continuous Glucose Monitors

Payment Policies

CYP2D6 Gene Analysis

Cell-Free Fetal DNA Test

Chelation Therapy

Chiropractic Services and Adjunctive Procedures (Adults and Children 13 years old and over)

Colorectal Cancer, Mutation Testing for Treatment

Compression Stockings and Garments

Computed Tomographic Colonography

Computed Tomography Angiography of the Chest

Continuous Home Pulse Oximetry

Continuous Passive Motion Devices

Cosmetic and Reconstructive Services

Cough Assist Devices


Medical Policies

Dental Anesthesia

Durable Medical Equipment, Corrective Appliances and Other Devices

Payment Policies

Deep Brain and Dorsal Column (Spinal Cord) Stimulators


Medical Policies


Experimental and Investigational

External Insulin Pumps

Extracranial Carotid Angioplasty with Stenting

Payment Policies


Endometrial Ablation

Endovascular Repair-Stent for Abdominal Aortic Aneurysm

External Counterpulsation Therapy

Eye-Anterior Segment Optical Coherence Tomography


Payment Policies

Facility Ambulance Transfer


Medical Policies

Gene Expression Testing Breast Cancer

Payment Policies

Genetic Testing for Cystic Fibrosis

Genetic Testing- Inherited Colorectal Cancers

Glaucoma, Invasive Procedures


Medical Policies

High Frequency Chest Wall Oscillation Devices

Payment Policies

Heart Disease, Lifestyle Modification Program

Hepatitis A Vaccine

High-Resolution Anoscopy

Home Apnea Monitoring

Home Oxygen Therapy

Home Sleep Study

Hospital Beds and Accessories

Human Papilloma Virus Testing

Human Papilloma Virus Vaccine

Hyperbaric Oxygen Therapy


Payment Policies

Incontinence, Biofeedback

Infertility- Diagnosis

Infertility- Treatment

Intensity-Modulated Radiation Therapy

Intraoperative Neurophysiological Testing

Intravascular Ultrasound of Coronary Vessels



Medical Policies

Lymphedema Pumps and Appliances

Payment Policies

Light Therapy in the Home, Ultraviolet B, Skin Conditions

Low Dose CT Scan for Lung Cancer Screening

Lower Limb Orthotics and Shoes


Medical Policies

Microprocessor Controlled Knee Prostheses

Molecular Susceptibility Testing for Breast and Ovarian Cancer

Molecular-Genetic Testing

Payment Policies

Magnetic Resonance Spectroscopy


Mammography, Computer-Aided Detection (CAD)

Management of Unlisted, Non-specific HCPCS and CPT Codes

Meningococcal Vaccine

Molecular Testing for Treatment of Melanoma


Medical Policies

Negative Pressure Wound Therapy

Non-Emergent Ambulance Transportation

Non-Invasive Bone Growth Stimulators

Nutritional Support

Payment Policies

Nerve Block, Paravertebral, Facet Joint, and SI Injections

Nerve Conduction Velocity Studies

Non-Vascular Extremity Ultrasoun


Medical Policies

Outpatient Mobile Real Time Cardiac Surveillance Systems

Payment Policies

Office-based Laryngeal Injections for Vocal Cord Augmentation

Oral Appliances for Obstructive Sleep Apnea


Medical Policies

Pancreatectomy with Autologous-Islet Cell Transplantation

Parenteral Nutrition

Power Mobility Devices

Prescribed Pediatric Extended Care Program

Pressure Reducing Support Surfaces- Groups 1, 2, and 3

Payment Policies

Plavix (Clopidogrel) Metabolism, Genetic Test

Posterior Tibial Nerve Stimulators

Presbyopia Correcting Intraocular Lenses (PIOLs) and Astigmatism Correcting Intraocular Lenses (ACIOLs)

Prophylactic Bilateral Salpingo-Oophorectomy

Prophylactic Mastectomy


Payment Policies

Radiofrequency Ablation

Rotavirus Vaccine

Routine Foot Care


Medical Policies

Selective Internal Radiation Therapy (SIRT)

Specialized Manual Wheelchairs

Payment Policies

Sacral Nerve Stimulators


Skin Substitutes- Human Skin Equivalents

Sleep Apnea Treatment, Positive Airway Pressure Devices

Speech Generating Devices

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Surgical Dressings and Wound Care Supplies


Medical Policies

Total Ankle Replacement

Transcatheter Aortic Valve Implantation (TAVI)

Transient Elastography

Transplant- Heart Lung

Transplant- Lung and Lobar Lung

Transplant- Pancreas Alone and Pancreas Kidney

Transplant- Pediatric Heart

Transplant- Small Bowel

Payment Policies


Temporomandibular Joint Disorders

Thryoid Nodule Molecular Testing

Topographic Genotyping

Transcutaneous Electrical Nerve Stimulators

Trigger Point and Transforaminal Epidural Injections


Medical Policies

Ventricular Assist Devices

Vertebral Augmentation

Payment Policies

Vagus Nerve Stimulators

Varicose Veins

Vision Therapy

Visually Evoked Response Test

Vysis ALK Break Apart FISH Test for the Selection of Xalkori


Medical Policies

Wearable Cardiac Defibrillator

Wheelchair Options and Accessories

Wheelchair Seating Options

Wireless Capsule Endoscopy


Payment Policies

Xiaflex (Collagenase Clostridium Histolyticum)


Payment Policies

Zostavax Vaccine