Medical Policies
The Medical Policies listed below are examples provided for informational purposes only.
These Medical Policies do not constitute medical advice. When deciding coverage, the terms of the enrollee’s plan and any applicable laws are referenced.
Plan terms are found in plan documents, including but not limited to Certificates of Coverage, Benefit Riders, and Summary Plan Descriptions.
SUMMARY OF BENEFITS & COVERAGE LOOKUP
The terms of an enrollee’s plan may differ from these Medical Policies. In the event of a conflict, the terms of the enrollee’s plan supersede the Medical Policy.
The list below is not a comprehensive list of Medical Policies. More recent versions of the Medical Policies, additional Medical Policies, MCG evidence-based care guidelines, and Coverage Determination Guidelines may also apply.
| Medical Policy | Policy Number |
|---|---|
| Acute Inpatient Rehabilitation Services* | |
| Airway Clearance Devices in the Ambulatory Setting* | C.11.01 |
| Ambulatory ECG Monitoring* | |
| Artificial Disc* | |
| Bariatric Surgery* | |
| Bioengineered Skin Substitutes* | |
| Bone Anchored Hearing Aid (BAHA)* | C.5.20 |
| Bone Growth Stimulation* | C.11.05 |
| Breast Reconstruction Post Mastectomy or Partial Mastectomy* | C.5.03 |
| Breast Reduction Surgery* | |
| CAR T Cell Therapy | C.6.30 |
| Cell-free DNA Testing for Fetal Aneuploidy | C.6.17 |
| Cochlear Implants* | |
| Continuous Glucose Monitoring Devices | C.11.09 |
| Continuous Passive Motion (CPM) Devices* | C.11.15 |
| Cosmetic and Reconstructive Surgery | C.5.14 |
| Cranial Orthotic Devices* | |
| Criteria for Rental, Replacement, Repair, Upgrade or Purchase of Durable Medical Equipment (DME) | C.11.18 |
| Deep Brain Stimulation* | |
| Dynamic Low-Load Prolonged-Duration Stretch (LLPS) Devices for Treatment of Contracture and Joint Stiffness | C.11.12 |
| Electric Tumor Treatment Fields (TTF) Device | C.11.23 |
| Endoscopic Myotomy Procedures for Treatment of Esophageal Achalasia and Gastroparesis | C.5.32 |
| Endoscopic Procedures & Non-Endoscopic Devices for Gastroesophageal Reflux Disease | C.5.27 |
| External Electrical Stimulators: Neuromuscular Electrical Stimulation (NMES), and Transcutaneous Electrical Nerve Stimulator (TENS)* | |
| Excimer Laser for Treatment of Psoriasis | C.6.28 |
| Endoscopic Procedures and Non-endoscopic Devices for Gastroesophageal Reflux Disease* | |
| Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions | C.5.11 |
| Gender Affirming Surgery | C.5.29 |
| Gender Affirming Surgery – ETF | C.5.36 |
| Genetic Testing | C.6.07 |
| Genetic Testing for Breast, Ovarian, Pancreatic or Prostate Cancer Syndromes including BRCA | C.6.21 |
| Heart Failure-Remote Monitoring (CardioMEMS™) | C.6.23 |
| Home Health Care* | |
| Home Phototherapy Devices (Narrowband UVB) | C.11.25 |
| Hospice Services | C.12.01 |
| Hospital Bed Rental/Purchase and Accessories* | |
| Hyperbaric Oxygen Therapy (HBOT)* | |
| Infertility Services | C.6.12 |
| Insulin Pump and Continuous Glucose Monitoring Systems* | |
| Left Atrial Appendage Closure | |
| Life-Sustaining Enteral Nutrition | C.6.05 |
| Long Term Acute Care (LTAC) | |
| Lymphedema* | |
| Manual Wheelchairs* | |
| Motorized Wheelchairs/Power Operated Vehicles (Scooters)* | |
| Negative Pressure Wound Therapy for Adults* | |
| Obstructive Sleep Apnea – Non-Surgical Treatment with Oral Appliance | C.11.06 |
| Obstructive Sleep Apnea – Surgical Treatment | C.5.04 |
| Patient Lift Equipment* | |
| Pectus Carinatum Orthotic Devices and Surgical Correction | C.11.27 |
| Pediatric Standing Frames or Stander* | |
| Penile Implants | |
| Peripheral Nerve Stimulation* | |
| Photodynamic Therapy* | |
| Platelet-Rich Plasma (PRP) Injections | C.13.01 |
| Prenatal/Preconception Genetic Testing to Determine Carrier State of a Parent or Prospective Parent | C.6.18 |
| Prolotherapy | C.16.13 |
| Proton Beam Therapy* | |
| Ptosis – Surgical Procedures* | |
| Radioembolization with Yttrium-90 Microspheres (TheraSphere and SIR-Spheres) | C.6.24 |
| Recurrent Pregnancy Loss | C.6.29 |
| Rhinoplasty / Septorhinoplasty* | |
| Robotic Procedures | C.5.19 |
| Skilled Nursing Facility (SNF) Services* | |
| Solid Organ and Hematopoietic Stem Cell Transplantation | C.5.17 |
| Spinal Cord Stimulation* | |
| Surgical Repair of Cartilage, Ligament, and Meniscal Defects of the Knee | C.5.33 |
| Surgical Treatment for Varicose Veins and Venous Insufficiency* | |
| Surgical Treatment of Temporomandibular Joint (TMJ) Disorders* | |
| Thermal Intradiscal Procedures | C.5.22 |
| Transcatheter Closure of Septal Defect | C.11.22 |
| Treatment of Obstructive Sleep Apnea Non-surgical* | |
| Treatment of Urinary and Fecal Incontinence | C.5.13 |
| Tumor Marker Genetics | C.6.34 |
| Vagus Nerve Stimulation for Seizure Disorders* | |
| Wearable Cardioverter Defibrillator* | |
| Whole Exome and Whole Genome Sequencing | C.6.35 |