| Rev#: | Date: | Nature of Change: |
|---|
| 4.0 | 03/05/2026 |
1100-1677764-1760950 The following policy has been archived effective 03/01/2026:
Aducanumab (Aduhelm) for Treatment of Alzheimer Disease
|
| 3.2 | 01/09/2026 |
1100-1677750-1671750 The following policy has been archived effective 01/01/2026:
Intravenous Anti-Microbial Therapy
|
| 3.1 | 08/01/2025 |
The following policy has been archived effective 8/1/2025:
1100-1205549-1430505 Services Related to the COVID-19 Public Health Emergency
|
| 3.0 | 01/21/2025 |
1100-1205500-1219251 The following policy has been archived effective 11/1/2024:
Extracranial Carotid Artery Stenting
|
| 2.5 (v21) | 12/27/2024 |
1100-956557-1205950 The following policies are archived effective 1/1/2025:
Continuous Glucose Monitoring Systems (QUEST Integration
Transitional Concurrent Care
|
| 2.4 (v20) | 08/06/2024 | 1100-956537-1106950
The following policy has been archived as of 5/1/2024:
Low-Molecular-Weight Heparin
|
| 2.3 (v19) | 06/14/2024
(published 6/20/24) | 1100-956527-1075303
The following entries have been updated for clarity:
Chiropractic Services
Occupational Therapy
Physical Therapy
|
| 2.2 (v18) | 06/03/2024 | 1100-956527-1058814
The following policies have been archived effective 6/1/2024:
Chiropractic Services
Occupational Therapy
Physical Therapy
Subcutaneous Implantable Cardioverter Defibrillator (ICD) System
|
| 2.1 (v17) | 03/06/2024 | Minor type edit. |
| 2.0 (v16) | 02/05/2024 | The following policies have been archived effective 2/1/2024:
Surgical Treatment of Femoroacetabular Impingement
Zevalin (Ibritumomab Tiuxetan)
|
| 1.12 (v15) | 12/21/2023 | The following policy has been archived eff 8/1/2023:
Anesthesia Services for Gastrointestinal Endoscopic Procedures
|
| 1.11 (v14) | 12/04/2023 | The following policy has been un-archived and removed from the table:
Drug testing in Pain Management and Substance Abuse Treatment
|
| 1.10 (v13) | 12/01/2023 | The following policy has been archived eff 12/1/2023:
Drug testing in Pain Management and Substance Abuse Treatment
|
| 1.9 (v12) | 09/07/2023 | The following policy has been archived effective 9/1/2023:
Computerized Corneal Topography
|
| 1.8 (v11) | 06/02/2023 | The following policies have been archived effective 6/1/2023. Superseded by Avalon GTM Program. Refer to Genetic Testing Medical Policies: Avalon.
Breast Cancer Assays of Genetic Expression in Tumor Tissue
Cardiovascular Risk Panels
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
Circulating Tumor DNA Management of Non0Small-Cell Lung Cancer (Liquid Biopsy)
Cytochrome P450 Genotype-Guided Treatment Strategy
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
Genetic Testing for BRCA1 or BRCA 2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers
Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies
Genetic Testing for Diagnosis and Management of Mental Health Conditions
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Genetic Testing for Non-Cancerous Inheritable Diseases
Genetic Testing of Inherited Cancer Predisposition
Genomic Profiling for Selecting Targeted Cancer Therapies
Molecular Marker in Fine Needle Aspirates of the Thyroid
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
Preimplantation Genetic Testing (PGT)
Prenatal Carrier Screening for Genetic Diseases
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
|
| 1.7 (v10) | 01/03/2023 | Hyperlinks to policy archive folders have been updated. |
| 1.6 (v9) | 08/22/2022 |
The following policy has been archived effective 7/1/2022:
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
|
| 1.5 (v8) | 08/01/2022 | The following policies have been archived effective 8/1/2022:
Kymriah (tisagenlecleucel)
Tecartus (Brexucabtagene Autoleucel)
Yescarta (Axicabtagene Ciloleucel)
|
| 1.4 (v7) | 07/05/2022 | The following policy has been archived effective 7/1/2022.
Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk
|
| 1.3 (v6) | 02/02/2022 | The following policy has been archived as of 2/1/2022:
Naturopathic Services
|
| 1.2 | 06/03/2021 | Archived policies that were active within the past two years can be accessed in their respective archived folders. Links have been updated. |
| 1.1 | 06/02/2021 | The following document(s) have been marked "ARCHIVED". The current source documents have been moved to a new document repository and links have been updated. Archived PDFs have been removed from record.
MM.07.028_Composite_Tissue_Allotransplantation_of_the_Hand_and_Face_102717_Archived
MM.07.028_Composite_Tissue_Allotransplantation_of_the_Hand_and_Face_122019_Archived
MM.07.028_Composite_Tissue_Allotransplantation_of_the_Hand_and_Face_111618_Archived
MM.07.027_Islet_Transplantation_102618_Archived
MM.07.027_Islet_Transplantation_032417_Archived
MM.02.024_Tilt_Table_Testing_082918_Archived
MM.02.024_Tilt_Table_Testing_092217_Archived
MM.01.014_Home_INR_Monitoring_052518_Archived
MM.01.014_Home_INR_Monitoring_080117_Archived
MM.01.012_Transcutaneous_Electrical_Nerve_Stimulation_(TENS)_090119_Archived
MM.06.002_Autologous_Chondrocyte_Implantation_for_Focal_Articular_Cartilage_Lesions_072718_Archived
MM.01.012_Transcutaneous_Electrical_Nerve_Stimulation_(TENS)_042718_Archived
MM.06.002_Autologous_Chondrocyte_Implantation_for_Focal_Articular_Cartilage_Lesions_120117_Archived |
| 1.0 | 08/05/2020 | Added the following links to the top of the page for user accessibility:
Medical Policies - CURRENT
Medical Policies - UNDER REVIEW |
| | 07/13/2020 | First published. |
