| Rev#: | Date: | Nature of Change: |
|---|
| 5.13 | 05/04/2026 | 1100-1677771-1845252 The contents of this page have been migrated to HMSA’s new policy transparency website that can be accessed here: https://hmsa.policytransparency.com/ |
| 5.12 | 04/20/2026 | 1100-1677771-1831324 Added a link to the Supportive Care form. |
| 5.11 | 04/15/2026 | 1100-1677771-1827152 Leadless Cardiac Pacemaker 60-day notice effective 5/1/2026, v2 has been posted. |
| 5.10 | 04/14/2026 | 1100-1677771-1818800 Liver Transplant and Combined Liver-Kidney Transplant, v2 has been posted. |
| 5.09 | 04/08/2026 | 1100-1677771-1800252 Link refresh for Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) |
| 5.08 | 04/07/2026 |
1100-1677771-1800252 The following policies effective 4/1/2026 have been posted:
Amvuttra® (Vutrisiran) and Onpattro® (Patisiran) for Hereditary Transthyretin-Mediated Amyloidosis in Adults
Casgevy® (Exagamglogene Autotemcel) and Lyfgenia® (Lovotibeglogene autotemcel) for Treatment of Sickle Cell Disease
Casgevy® (Exagamglogene Autotemcel) and Zynteglo® (Betibeglogene autotemcel) for Treatment of β-Thalassemia (Formerly: Zynteglo® (Betibeglogene autotemcel) for Treatment of β-Thalassemia)
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
Habilitative/Rehabilitative Physical Medicine Services: Chiropractic, Occupational Therapy, and Physical Therapy
Hyperbaric Oxygen Therapy (HBOT)
Image-Guided Radiation Therapy (IGRT)
In Vitro Fertilization
Intranasal Esketamine for Major Depressive Disorder with Acute Suicidality and Treatment-Resistant Depression
IV Ketamine Infusion as an Alternative to ECT
Observation Services
Precertification Requirements - HMSA Medicare Advantage Plans
Radiology: Advanced Imaging Studies
Speech Therapy Services: Habilitative
Transcranial Magnetic Stimulation for the Treatment of Depression and Other Psychiatric/Neurologic Disorders
Vyjuvek® (Beremagene geperpavec-svdt) and Zevaskyn® (Prademagene zamikeracel) for Treatment of Wounds in Dystrophic Epidermolysis Bullosa
|
| 5.07 | 03/06/2026 | 1100-1677764-1770150 The Services Related to the COVID-19 Public Health Emergency policy archived effective 08/01/2025 has been removed from the current policy table. |
| 5.06 | 03/05/2026 |
1100-1677764-1769700 The Intravenous Anti-Microbial Therapy policy archived effective 01/01/2026 has been removed from the current policy table.
1100-1677764-1760951 The following policies effective 3/1/2026 have been posted:
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry, ARCHIVED: policy eff 8/23/2024
Brachytherapy, ARCHIVED: policy eff 3/1/2025
Breast Pumps, ARCHIVED: policy eff 8/23/2024
Continuous Glucose Monitoring System, ARCHIVED: policy eff 1/1/2025
Stereotactic Radiosurgery & Stereotactic Body Radiotherapy, ARCHIVED: policy eff 8/1/2024
1100-1677764-1760950 Effective 3/1/2026, the Aducanumab (AduhelmTM) for Treatment of Alzheimer Disease has been archived.
|
| 5.05 | 03/02/2026 | 1100-1677764-1758263 The following 60-day notices effective 5/1/2026 have been posted:
Laser Therapy for Plaque Psoriasis
Leadless Cardiac Pacemaker
Change history entries from 01/04/2022-12/30/2022 have been removed. |
| 5.04 | 02/17/2026 |
1100-1677757-1739563 Removed the Routine Testing Management (RTM) Guidelines quick link as the page has been archived.
1100-1677757-1739952 Posted the Oxygen and Oxygen Equipment, 6/27/2025, v2
|
| 5.03 | 02/06/2026 | 100-1677757-1723601 The following 60-day notices effective 4/1/2026 have been posted (previously missed):
Speech Therapy Services: Habilitative
Vyjuvek® (Beremagene geperpavec-svdt) and Zevaskyn® (Prademagene zamikeracel) for Treatment of Wounds in Dystrophic Epidermolysis Bullosa |
| 5.02 | 02/05/2026 |
100-1677757-1723601 The following 60-day notices effective 4/1/2026 have been posted:
Amvuttra (Vutrisan) and Onpattro (Patisiran) for Hereditary Transthyretin-Mediated Amyloidosis in Adults
Casgevy® (Exagamglogene Autotemcel)and Lyfgenia® (Lovotibeglogene autotemcel) for the Treatment of Sickle Cell Disease
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
Habilitative/Rehabilitative Physical Medicine Services: Chiropractic, Occupational Therapy, and Physical Therapy
Hyperbaric Oxygen Therapy
Image-Guided Radiation Therapy (IGRT)
In Vitro Fertilization
Intranasal Esketamine for Major Depressive Disorder with Acute Suicidality and Treatment-Resistant Depression
IV Ketamine Infusions as an Alternative to Electroconvulsive Therapy (ECT)
Observation Services
Precertification Requirements HMSA Medicare Advantage Plans
Radiology: Advanced Imaging Studies
Speech Therapy Services: Habilitative
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Vyjuvek® (Beremagene geperpavec-svdt) and Zevaskyn® (Prademagene zamikeracel) for Treatment of Wounds in Dystrophic Epidermolysis Bullosa
1100-1677757-1720723 The Liver Transplant and Combined Liver-Kidney Transplant policy, eff 2/1/2026 has been posted. ARCHIVED: policy eff 12/20/2024.
|
| 5.01 | 01/29/2026 | 1100-1677750-1708300 The following policies effective 1/26/2026 have been posted:
Bone Mineral Density Studies, ARCHIVED: 11/01/2025
Cardiac Rehabilitative Studies, ARCHIVED: 4/25/2025
Positive Airway Pressure and Oral Devices, ARCHIVED: 11/01/2025
Telehealth Services, ARCHIVED: 4/01/2025 |
| 5.00 | 01/09/2026 |
1100-1677750-1678652 The following redlined 60-day notices effective 3/1/2026 have been posted:
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Brachytherapy
Breast Pumps
Continuous Glucose Monitoring System
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
1100-1677750-1678658 Aduhelm (Aducanumab) for Treatment of Alzheimer Disease MM.02.052 60-day ARCHIVAL NOTICE effective 03/01/2026 has been posted.
1100-1677750-1678650 Immunizations effective 01/01/2026 has been posted.
1100-1677750-1679250 The following policies effective 01/01/2026 have been posted:
Preventive Health Guidelines - Men; ARCHIVED: 60-day notice and policy 7/1/2025
Preventive Health Guidelines - Newborns and Children; ARCHIVED: 60-day notice and policy 7/1/2025
Preventive Health Guidelines - Prenatal Care; ARCHIVED: 60-day notice and policy 7/1/2025
Preventive Health Guidelines - Women; ARCHIVED: 60-day notice and policy 7/1/2025
Gender Identity Services; ARCHIVED: 60-day notice and policy 2/1/2025
Hepatic Elastography for Chronic Liver Disease; ARCHIVED: 60-day notice and policy 5/1/2025
1100-1677750-1671750
Intravenous Anti-Microbial Therapy has been archived effective 01/01/2026
The following archived policies have been removed from the article:
Services Related to COVID-19 archival effective 8/1/2025
Chiropractic Services (Refer to Habilitative/Rehabilitative Physical Medicine Services: Chiropractic, Occupational Therapy, and Physical Therapy)
Occupational Therapy (Refer to Habilitative/Rehabilitative Physical Medicine Services: Chiropractic, Occupational Therapy, and Physical Therapy)
Physical Therapy (Refer to Habilitative/Rehabilitative Physical Medicine Services: Chiropractic, Occupational Therapy, and Physical Therapy)
|
| r4.59 | 12/26/2025 |
1100-1205577-1665780 The following policies effective 12/19/2025, v2 have been posted:
Bariatric Surgery
Durable Medical Equipment, Prosthetics and Orthotics (HMO, PPO)
The Digital Breast Tomosynthesis 3D effective date has been updated to 12/19/2025.
|
| 4.58 | 12/24/2025 | 1100-1205577-1665780 The following policies effective 12/19/2025 have been posted:
Artificial Insemination; ARCHIVED: 12/20/2024
Autonomic Nervous System Testing; ARCHIVED: 10/25/2024
Bariatric Surgery; ARCHIVED: 12/20/2024
Brexanolone for Major Depression with Peripartum Onset; ARCHIVED: 12/20/2024
Bronchial Thermoplasty; ARCHIVED: 12/20/2024
Cognitive Rehabilitation Therapy; ARCHIVED: 12/20/2024
Colonoscopy; ARCHIVED: 11/15/2024
Colorectal Cancer Screening; ARCHIVED: 11/15/2024
Deep Sedation and General Anesthesia for Dental Services; ARCHIVED: 12/20/2024
Digital Breast Tomosynthesis; ARCHIVED: 12/20/2024
Durable Medical Equipment, Prosthetics & Orthotics (Sm Grp, Ind, Fed87, QI); ARCHIVED: 12/20/2024
Durable Medical Equipment, Prosthetics and Orthotics (HMO, PPO); ARCHIVED: 12/20/2024
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus; ARCHIVED: 12/20/2024
Extracorporeal Membrane Oxygenation (ECMO); ARCHIVED: 9/27/2024
Givlaari® (Givosiran); ARCHIVED: 4/1/2024
Hemgenix and Roctavian; ARCHIVED: 5/1/2024
Oxlumo (Lumasiran); ARCHIVED: 4/1/2024
Readmissions and Transfers; ARCHIVED: 5/24/2024
Speech Therapy Services, Rehabilitative; ARCHIVED:
Spinal Orthoses Thoracic-Lumbar-Sacral (TLSO); ARCHIVED: 12/20/2024
Testosterone Replacement Therapies; ARCHIVED: 10/25/2024
Zolgensma (Onasemnogene Abeparvovec-xioi); ARCHIVED: 4/1/2024 |
| 4.57 | 12/10/2025 | 1100-1205577-1648800 Intranasal Esketamine for MDD with Acute Suicidality and TRD, 1/1/2025, v4 has been posted. |
| 4.56 | 12/08/2025 | 1100-1205577-1646600 Drug Testing in Pain Management and Substance Abuse Treatment, 12/01/2025 v2 has been posted. Updated the Dx code list link in the table. |
| 4.55 | 12/04/2025 |
1100-1205577-1634450 The Liver Transplant and Combined Liver-Kidney Transplant redline 60-day notice eff 02/01/2026 has been posted.
1100-1205577-1639565 The following policies effective 12/01/2025 have been posted:
High-Frequency Chest Wall Oscillation Devices and Other Airway Clearance Therapy Devices; ARCHIVED: 60-day notice and policy eff 12/01/2024
Spinal Cord and Dorsal Root Ganglion Stimulation; ARCHIVED: 60-day notice and policy eff 12/20/2024
Transcatheter Aortic-Valve Implantation for Aortic Stenosis (TAVR); ARCHIVED: 60-day notice and policy eff 04/26/2024
1100-1205577-1642511 The following redline 60-day notices effective 01/26/2026 have been posted:
Bone (Mineral) Density Studies
Cardiac Rehabilitative Services
Positive Airway Pressure and Oral Devices
Telehealth Services
|
| 4.54 | 11/26/2025 | 1100-1205570-1634000 The following policies effective 11/21/2025 have been posted:
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions; ARCHIVED: 12/20/2024
Chimeric Antigen Receptor (CAR) T-Cell Therapies for the Treatment of Cancer; ARCHIVED: 23/20/2024 v3
Polysomnography and Home Sleep Apnea Testing; ARCHIVED: 2/1/2025
Risk Reducing Mastectomy; ARCHIVED: 12/20/2024 |
| 4.53 | 11/20/2025 | 1100-1205570-1624950 Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) v2 has been posted. |
| 4.52 | 11/10/2025 | 1100-1205570-1593907 The following 60-day notices eff 1/1/2026, v2 have been posted; links to the billing instruction and code information have been updated.
Preventive Health Guidelines - Men
Preventive Health Guidelines - Newborns and Children
Preventive Health Guidelines - Prenatal Care
Preventive Health Guidelines - Women |
| 4.51 | 11/07/2025 |
1100-1205570-1593914 The following policies effective 11/1/2025 have been posted:
Bone (Mineral) Density Studies; ARCHIVED: 60-day notice and policy eff 12/20/2024
Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea; ARCHIVED: 60-day notice and policy eff 2/1/2025
Osteopathic Manipulative Treatment; ARCHIVED: 60-day notice and policy eff 8/23/2024
Positive Airway Pressure and Oral Devices; ARCHIVED: 60-day notice and policy eff 2/1/2025
1100-1205570-1593854 Immunizations, 60-day notice eff 1/1/2026 has been posted.
1100-1205570-1593907 The following 60-day notices eff 1/1/2026 have been posted:
Preventive Health Guidelines - Men
Preventive Health Guidelines - Newborns and Children
Preventive Health Guidelines - Prenatal Care
Preventive Health Guidelines - Women
Hepatic Elastography for Liver Disease
Gender Identity Services
|
| 4.50 | 10/30/2025 | 1100-1205563-1603256 MM.12.015 TMS Treatment of Depression and Other Psychiatric-Neurologic Disorders, effective 9/1/2025, v2 has been posted. |
| 4.49 | 10/29/2025 | 1100-1205563-1585050 The following policies effective 10/24/2025 have been posted:
3D Reconstruction; ARCHIVED: policy eff 12/20/2024
Allogeneic Pancreas Transplant; ARCHIVED: policy eff 12/20/2024
Catheter Ablation as Treatment for Atrial Fibrillation; ARCHIVED: policy eff 10/25/2024
Clinical Trials- Routine Costs; ARCHIVED: policy eff 12/20/2024
Computer-Assisted Navigation for Orthopedic Procedures; ARCHIVED: policy eff 07/26/2024
Heart Transplant; ARCHIVED: policy eff 12/20/2024
Heart-Lung Transplant; ARCHIVED: policy eff 12/20/2024
Home Health Care (Commercial); ARCHIVED: policy eff 12/20/2024
Home Health Care (QUEST Integration); ARCHIVED: policy eff 12/20/2024
Intensity Modulated Radiation Therapy (IMRT); ARCHIVED: policy eff 4/1/2025
Isolated Small Bowel Transplant; ARCHIVED: policy eff 12/20/2024
Knee Orthoses for Osteoarthritis; ARCHIVED: policy eff 12/20/2024
Lung and Lobar Lung Transplant; ARCHIVED: policy eff 12/20/2024
Negative Pressure Wound Therapy; ARCHIVED: policy eff 12/20/2024
Never Events and Hospital-Acquired Conditions (HAC); ARCHIVED: policy eff 12/20/2024
Occlusion of Uterine Arteries Using Transcatheter Embolization; ARCHIVED: policy eff 12/20/2024
Percutaneous Left Atrial Appendage Closure Devices; ARCHIVED: policy eff 12/20/2024
Posterior Tibial Nerve Stimulation; ARCHIVED: policy eff 12/20/2024
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors; ARCHIVED: policy eff 12/20/2024
Small Bowel-Liver Multivisceral Transplant; ARCHIVED: policy eff 12/20/2024
Total Artificial Hearts and Implantable Ventricular Assist Devices; ARCHIVED: policy eff 10/25/2024
Treatment of Hyperhidrosis; ARCHIVED: policy eff 12/20/2024 |
| 4.48 | 10/16/2025 | 1100-1205563-1578600 Drug testing in Pain Management and Substance Abuse Treatment, eff 12/01/2025 has been posted. ARCHIVED: 60-day notice and policy eff 12/01/2023.
10/07/2025: 1100-1205563-1551600 The Leadless Cardiac Pacemaker policy, eff 1/1/2025, v2 has been posted. |
| 4.47 | 10/06/2025 | 1100-1205563-1545475 The following 60-day notices effective 12/01/2025 have been posted:
Drug testing in Pain Management and Substance Abuse Treatment
High-Frequency Chest Wall Oscillation Devices Other Airway Clearance Therapy
Spinal Cord and Dorsal Root Ganglion Stimulation
Transcatheter Aortic-Valve Implantation for Aortic Stenosis (TAVR) |
| 4.46 | 09/30/2025 | 1100-1205556-1536302 The following have been posted:
Hyperbaric Oxygen Therapy policy eff 4/1/2025, v2
HBOT Payable Dx Codes eff 10/01/2025 |
| 4.45 | 09/29/2025 | 1100-1205556-1538750 The following policies eff 9/26/2025 have been posted:
Fecal Microbiota Transplant; ARCHIVED policy eff: 10/25/2024
Incontinence Supplies; ARCHIVED policy eff: 4/1/2025
Lutathera (Lutetium 177); ARCHIVED policy eff: 10/25/2024
Sepsis and Septic Shock; ARCHIVED policy eff: 12/20/2024 |
| 4.44 | 09/25/2025 | 1100-1205556-1536300 Treatment of Varicose Veins, 8/22/2025, v2 has been posted. |
| 4.43 | 09/11/2025 | 1100-1205556-1514400 Continuous Glucose Monitoring Systems, 1/1/2025, v3 has been posted. |
| 4.42 | 09/05/2025 | 1100-1205556-1505156 The Applied Behavior Analysis Precertification Request Form updated 8/2025 has been posted. |
| 4.41 | 09/04/2025 | 1100-1205556-1489350 Corrected the listed effective date to 9/1/2025 for the following:
Medical Nutrition Therapy
Post-acute Residential Treatment Facility and CCFFH |
| 4.40 | 09/03/2025 |
1100-1205556-1489350 The following policies effective 09/01/2025 have been posted:
Applied Behavior Analysis for Treatment of Autism Spectrum Disorder; ARCHIVED: policy eff 03/01/2025
Medical Nutrition Therapy; ARCHIVED: policy eff 12/20/2024
Post-acute Residential Treatment Facility and CCFFH; ARCHIVED: policy eff 12/20/2024
Transcranial Magnetic Stimulation, Treatment, Depression, and Other Psychiatric-Neurologic Disorders; ARCHIVED: policy eff 01/01/2025
1100-1205556-1489355 The following redlined 60-day notices, effective 11/01/2025 have been posted:
Bone Mineral Density Studies
Hypoglossal Nerve Stimulation
Osteopathic Manipulative Treatment
Positive Airway Pressure and Oral Devices
1100-1205556-1502650 The following policies effective 08/16/2025 have been posted. ARCHIVED: 60-day notice and policies effective 06/01/2025.
Palliative Care
Supportive Care
1100-1205556-1490103 The Intravenous Anti-Microbial Therapy 60-day archival notice eff 11/1/2025 has been posted.
|
| 4.39 | 08/25/2025 |
1100-1205549-1486800 Posted: Dietetic Treatment of Eating Disorders, 5/23/2025; ARCHIVED: policy eff 12/20/2024.
1100-1205549-1483054 The following policies eff 8/22/2025 have been posted:
Compression Garments; ARCHIVED: policy eff 9/1/2024
Hip Knee and Shoulder Surgery; ARCHIVED: policy eff 1/1/2025
Home Continuous Inotropic Infusion Therapy; ARCHIVED: policy eff 8/23/2025
Home Infusion Pain Management Therapy; ARCHIVED: policy eff 8/23/2025
Out of State Air Ambulance Services; ARCHIVED: policy eff 8/23/2025
Spinal Interventional Pain Management and Spine Surgery; ARCHIVED: policy eff 1/1/2025
Transcatheter Closure of Patent Foramen Ovale for Stroke Prevention; ARCHIVED: policy eff 2/1/2025
Transcatheter Mitral Valve Repair; ARCHIVED: policy eff 3/1/2025
Transcatheter Pulmonary Valve Implantation; ARCHIVED: policy eff 8/23/2025
Treatment of Varicose Veins; ARCHIVED: policy eff 12/20/2024
1100-1205549-1470251 MM.02.016 Dermatologic Applications of Photodynamic Therapy, 4/25/2025 v2 has been posted. (uploaded on 8/15/2025)
|
| 4.38 | 08/01/2025 |
1100-1205549-1430505 Services Related to the COVID-19 Public Health Emergency policy has been archived effective 8/1/2025.
1100-1205549-1430505 Glaucoma Treatments, 8/1/2025 has been posted. ARCHIVED: 60-day notice and policy eff 11/1/2024.
Change history entries from 2/6/2020-12/30/2021 have been removed.
|
| 4.37 | 07/28/2025 | 1100-1205542-1430501 Posted the Insulin Pumps External policy eff 7/25/2025. |
| 4.36 | 07/24/2025 |
1100-1205542-1427100 Updated the link to the Behavioral Health Prior Authorization Form for the following in the policy table:
Post-acute, Residential Treatment Facility and Community Care Foster Family Home Care
Post-acute and Residential Treatment Facility Stays
|
| 4.35 | 07/23/2025 | 1100-1205542-1426400 The following policies have been reposted with a fix to a broken link.
Post-acute, Residential Treatment Facility and Community Care Foster Family Home Care, 60-day notice eff 9/1/2025, v2
Post-acute, Residential Treatment Facility and Community Care Foster Family Home Care, 12/20/2025, v2
Post-acute and Residential Treatment Facility Stays, 4/25/2025, v2 |
| 4.34 | 07/17/2025 | 1100-1205542-1415900 Posted the revised policy Chimeric Antigen Receptor (CAR) T-Cell Therapies for the Treatment of Cancer, 12/20/2024 v3
1100-1205542-1417500 Posted the revised policy Preventive Health Guidelines: Prenatal Care, 7/1/2025 v3 |
| 4.33 | 07/15/2025 | 1100-1205542-1412002 The following have been posted:
Preventive Health Guidelines - Men, 7/1/2025, v2
Preventive Health Guidelines - Prenatal Care, 7/1/2025, v2
Preventive Health Guidelines - Women, 7/1/2025, v2
Preventive Health Guidelines - Newborns and Children, 7/1/2025, v2 |
| 4.32 | 07/02/2025 | 1100-1205542-1397401 The medical policy Medical Nutrition Therapy, 12/20/2024, v2 has been posted. |
| 4.31 | 07/01/2025 |
1100-1205542-1381970 The following policies effective 7/1/2025 have been posted:
High-Intensity Focused Ultrasound (HIFU) Ablation for Prostate Cancer; ARCHIVED: 60-day notice
Home Nutrition Therapy; ARCHIVED: 60-day notice and policy eff 11/15/2024
Preventive Health Guidelines - Men; ARCHIVED: 60-day notice and policy eff 1/1/2025
Preventive Health Guidelines - Prenatal Care; ARCHIVED: 60-day notice and policy eff 1/1/2025
Preventive Health Guidelines - Women; ARCHIVED: 60-day notice and policy eff 1/1/2025
Preventive Health Guidelines - Newborns and Children; ARCHIVED: 60-day notice and policy eff 1/1/2025
1100-1205542-1381977 The following redlined 60-day notices effective 9/1/2025 have been posted:
Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder
Medical Nutrition Therapy
Post-acute, Residential Treatment Facility and Community Care Foster Family Home Care
Transcranial Magnetic Stimulation as a Treatment of Depression and other Psychiatric/Neurologic Disorders
|
| 4.30 | 06/27/2025 |
1100-1205535-1381982 The following policies effective 06/27/2025 have been posted:
Corneal Collagen Cross-Linking; ARCHIVED: policy eff 5/24/24
Home Total Parenteral Nutrition (NEW title: formerly Home Total Parenteral Nutrition for Adults); ARCHIVED: policy eff 11/15/24
Medical Foods for Inborn Errors of Metabolism; ARCHIVED: policy eff 11/15/24
Observation Services; ARCHIVED: policy eff 11/15/24
Oxygen and Oxygen Equipment; ARCHIVED: policy eff 7/26/24
|
| 4.29 | 06/23/2025 | 1100-1205535-1379600 MM.02.048 Intranasal Esketamine for MDD with Acute Suicidality and TRD 2025-0101_v3 policy has been posted. Also updated the link to the current billing and coding guideline, eff 6/20/2025. |
| 4.28 | 06/16/2025 |
1100-1205535-1374100 Added 60-day notices eff 8/16/2025 for the following policies:
Palliative Care
Supportive Care
|
| 4.27 | 06/04/2025 |
1100-1205535-1354050 The following policies effective 6/1/2025 have been posted:
Palliative Care (Quest Integration); ARCHIVED 60-day notice
Supportive Care; ARCHIVED 60-day notice and policy eff 10/1/2024, v2
1100-1205535-1354053 The following 60-day notices effective 8/1/2025 have been posted:
Glaucoma Treatments
Services Related to COVID-19, archival notice
|
| 4.26 | 06/02/2025 | 1100-1205528-1356546 The following policies effective 5/23/2025 have been posted:
Amniotic Membrane and Amniotic Fluid, ARCHIVED policy eff 12/1/2024
Bioengineered Skin and Soft Tissue Substitutes, ARCHIVED policy eff 10/25/2024, v2
Pulmonary Rehabilitation, ARCHIVED policy eff 4/1/2025
Sensory Integration Therapy and Auditory Integration Therapy, ARCHIVED policy eff 12/20/2024
Vagus Nerve Stimulation, ARCHIVED policy eff 4/26/2024 |
| 4.25 | 05/30/2025 | 1100-1205528-1356653 The 2025 Supportive Care Handbook has been posted. Located with the additional information for the Supportive Care policy. |
| 4.24 | 05/21/2025 | 1100-1205528-1349700 The following revised (v2) redline 60-day notices eff 7/1/2025 have been posted:
Preventive Health Guidelines - Men
Preventive Health Guidelines - Newborns and Children
Preventive Health Guidelines - Prenatal
Preventive Health Guidelines - Women |
| 4.23 | 05/05/2025 | 1100-1205528-1330250 Bone (Mineral) Density Studies, eff 12/20/2024 has been posted. ARCHIVED: policy eff 4/1/2025. |
| 4.22 | 05/02/2025 | 1100-1205528-1319002 The following policies have been posted effective 5/1/2025:
Hepatic Elastography for Chronic Liver Disease; ARCHIVED: 60-day notice and policy eff 6/1/2024
Lenmeldy (Atidarsagene Autotemcel) for Metachromatic Leukodystrophy; ARCHIVED: 60-day notice
Pulse Oximeter (Formerly: Pulse Oximeter for Children); ARCHIVED: 60-day notice and policy eff 12/20/2024
1100-1205528-1321550 New policy 60-day notice eff 7/1/2025 has been posted: High-Intensity Focused Ultrasound (HIFU) Ablation for Prostate Cancer. Added to policy table.
1100-1205528-1321500 The following redline 60-day notices eff 7/1/2025 have been posted:
Preventive Health Guidelines - Men
Preventive Health Guidelines - Newborns and Children
Preventive Health Guidelines - Prenatal
Preventive Health Guidelines - Women |
| 4.21 | 04/28/2025 |
100-1205521-1323300 The Hepatic Elastography for Chronic Liver Disease redlined 60-day notice, v2 has been posted.
|
| 4.20 | 04/25/2025 | 1100-1205521-1319006 The following policies effective 4/25/2025 have been posted:
Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias; ARCHIVED policy eff 3/22/2024
Allogeneic Stem Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms; ARCHIVED policy eff 3/22/2024
Cardiac Rehabilitation in the Outpatient Setting; ARCHIVED policy eff 1/1/2025, v2
Cosmetic and Reconstructive Surgery and Services; ARCHIVED policy eff 5/24/2024
Dermatologic Applications of Photodynamic Therapy; Formerly: Photodynamic Therapy for the Treatment of Actinic Keratosis and Other Skin Lesions; ARCHIVED policy eff 2/23/2024
Erectile Dysfunction; ARCHIVED policy eff 8/23/2024
Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Hodgkin Lymphoma; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Acute Myeloid Leukemia; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Autoimmune Diseases; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Primary Amyloidosis; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Solid Tumors of Childhood; ARCHIVED policy eff 3/22/2024
Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia; ARCHIVED policy eff 3/22/2024
Kyphoplasty and Vertebroplasty; ARCHIVED policy eff 9/1/2024
Luxturna (Voretigene Neparvovec-rzyl); ARCHIVED policy eff 10/25/2024
Post-acute and Residential Treatment Facility Stays; ARCHIVED policy eff 12/20/2024
Reduction Mammaplasty for Breast-Related Symptoms; ARCHIVED policy eff 6/28/2024 |
| 4.19 | 04/01/2025 |
1100-1205514-1292752 The following policies eff 4/01/2025 have been posted:
Bone (Mineral) Density Studies; ARCHIVED: 60-day notice and policy eff 4/01/2024, v2
Cardiac-Related Procedures; ARCHIVED: 60-day notice and policy eff 4/01/2024
Hyperbaric Oxygen Therapy (HBOT); ARCHIVED: 60-day notice and policy eff 11/01/2023
Image-Guided Radiation Therapy (IGRT); ARCHIVED: 60-day notice and policy eff 3/01/2024
Incontinence Supplies; ARCHIVED: 60-day notice and policy eff 11/17/2023
Intensity Modulated Radiation Therapy (IMRT); ARCHIVED: 60-day notice and policy eff 3/22/2023
Pulmonary Rehabilitation; ARCHIVED: 60-day notice and policy eff 11/17/2023
Radiology: Advanced Imaging Studies; ARCHIVED: 60-day notice and policy eff 7/01/2024
Telehealth Services; ARCHIVED: 60-day notice and policy eff 12/1/2023
|
| 4.18 | 03/28/2025 |
1100-1205514-1294950 The following policies eff 3/28/2025 have been posted:
Blepharoplasty and Repair of Blepharoptosis; ARCHIVED: policy eff 2/23/2024
Esophageal pH Monitoring; ARCHIVED: policy eff 9/1/2024
Hemophilia A and B Products; ARCHIVED: policy eff 10/25/2024
Intravenous (IV) Hydration Therapy **formerly known as “Intravenous (IV) Hydration Therapy for Adults”; ARCHIVED: policy eff 7/26/2024
Orthodontic Treatment of Orofacial Anomalies; ARCHIVED: policy eff 4/26/2025
Panniculectomy/Abdominoplasty; ARCHIVED: policy eff 2/23/2024
|
| 4.17 | 03/27/2025 | 1100-1205514-1292750 Posted Supportive Care redlined 60-day notice eff 6/1/2025. |
| 4.16 | 03/21/2025 | 1100-1205514-1288700 The following have been posted:
Precertification Request Form - Behavioral Health Services
IV Ketamine Infusions as an Alternative to Electroconvulsive Therapy (ECT), 1/1/2025, v3
Intranasal Esketamine for Major Depressive Disorder with Acute Suicidality and Treatment-Resistant Depression, 1/1/2025, v2 |
| 4.15 | 03/20/2025 |
1100-1205514-1286800 Posted Continuous Glucose Monitoring Systems (CGMS), 1/1/2025, v2
|
| 4.14 | 03/13/2025 |
1100-1205514-1278950 Posted Palliative Care 60-day notice effective 6/1/2025. Added a new row to the table.
|
| 4.13 | 03/04/2025 |
1100-1205514-1261255 The following policies have been posted:
Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder, 3/1/2025; ARCHIVED: 60-day notice and policy eff 11/1/2023
Brachytherapy, 3/1/2025; ARCHIVED: 60-day notice and policy eff 11/7/2023
Transcatheter Mitral Valve Repair, 3/1/2025; ARCHIVED: 60-day notice and policy eff 12/1/2023
1100-1205514-1261858 The following redlined 60-day notices have been posted:
Hepatic Elastography for Chronic Liver Disease
Pulse Oximeter
|
| 4.12 | 03/03/2025 |
1100-1205514-1261856 The Complementary and Alternative Medicine policy effective 2/28/2025 has been posted. ARCHIVED: policy effective 07/26/2024.
1100-1205514-1261254 The Transitional Concurrent Care policy archived eff 1/1/2025, has been removed from the policy table.
1100-1205514-1261861 Posted the Lenmeldy (Atidarsagene Autotemcel) for Metachromatic Leukodystrophy 60-day notice eff 5/1/2025 and added a new row to the applicable table.
|
| 02/25/2025 | 1100-1205507-1254953 The following policies have been posted and previous versions archived:
Chimeric Antigen Receptor (CAR) T-Cell Therapies for the Treatment of Cancer, v2 [Formerly: Chimeric Antigen Receptor T-Cell Therapies for Leukemia and Lymphoma]
Casgevy® (Exagamglogene Autotemcel) and Lyfgenia® (Lovotibeglogene autotemcel) for the Treatment of Sickle Cell Disease, v3
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy, v2
|
| 4.11 | 02/18/2025 |
1100-1205507-1247500 MM.12.027 Telehealth Services REDLINE 60-day notice eff 2025-0401 v2 has been posted.
|
| 4.10 | 02/05/2025 |
1100-1205507-1232100 The following policies archived eff 11/1/2024, have been removed from the policy table:
Extracranial Carotid Artery Stenting
Photochemotherapy
|
| 4.9 | 02/04/2025 |
1100-1205507-1234056 The Speech Therapy Services - Habilitative, 1/01/2025, v2 has been posted.
1100-1205507-1232100 The following policies archived eff 11/1/2024, have been removed from the policy table:
Extracranial Carotid Artery Stenting
Photochemotherapy
1100-1205507-1231810 The following redline 60-day notices effective 4/1/2025 have been posted:
Bone (Mineral) Density Studies
Cardiac-Related Procedures
Hyperbaric Oxygen Therapy
Image Guided Radiation Therapy
Incontinence Supplies
Intensity Modulated Radiation Therapy (IMRT)
Pulmonary Rehabilitation
Radiology, Advanced Imaging Studies
Telehealth Services
1100-1205507-1234054 Cardiac Rehabilitation in the Outpatient Setting, 1/1/2025, v2 has been posted.
1100-1205507-1231804 The following have been posted:
Gender Identity Services, 2/1/2025 ARCHIVED: 60-day notice and policy eff 12/15/2023, v2
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, 2/1/2025 ARCHIVED: 60-day notice and policy eff 2/1/2024
Polysomnography and Home Sleep Apnea Testing, 2/1/2025 ARCHIVED: 60-day notice and policy eff 2/1/2024 v2
Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea, 2/1/2025 ARCHIVED: 60-day notice and policy eff 8/1/2023
Transcatheter Closure of Patent Foramen Ovale for Stroke Prevention and Atrial Septal Defects, 2/1/2025 ARCHIVED: 60-day notice and policy eff 6/23/2023 (Title change. Formerly: Transcatheter Closure of Patent Foramen Ovale for Stroke Prevention)
|
| 4.8 | 01/31/2025 |
1100-1205500-1231100 Posted Supportive Care, 10/1/2024, v2
|
| 4.7 | 01/27/2025 |
1100-1205500-1225702 The following policies have been posted. ARCHIVED: 60-day notice, policy and coding guidelines eff 7/1/2024.
Preventive Health Guidelines - Men, 1/1/2025
Preventive Health Guidelines - Newborns and Children, 1/1/2025
Preventive Health Guidelines - Prenatal Care, 1/1/2025
Preventive Health Guidelines - Women, 1/1/2025
|
| 4.6 | 01/23/2025 |
1100-1205500-1221550 Luxturna (Voretigene Neparvovec-rzyl) link refresh.
1100-1205500-1221350 MM.12.015 Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric-Neurologic Disorders, v2 has been posted.
|
| 4.5 | 01/22/2025 |
1100-1205500-1220602 The following policy has been updated:
Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder 60-day notice, eff 3/1/2025
|
| 4.4 | 01/21/2025 |
1100-1205500-1219251 The following policies have been archived effective 11/1/2024:
Extracranial Carotid Artery Stenting
Photochemotherapy
The Subcutaneous Implantable Cardioverter Defibrillator (ICD) System policy archived eff 6/1/2024, has been removed from the policy table.
|
| 4.3 | 01/17/2025 |
The following have been posted:
1100-1205500-1215651 Applied Behavior Analysis Therapy for Autism Spectrum disorder, 60-day notices eff 3/1/2025, v2
|
| 4.2 | 01/16/2025 |
The following have been posted:
1100-1205500-1215800 Bioengineered Skin and Soft Tissue Substitutes, 10/25/2024, v2
1100-1205500-1215800 Luxturna (Voretigene Neparovec-rzyl), 10/25/2024, v2
1100-1205500-1215651 Transcatheter Mitral Valve Repair, 60-day notices eff 3/1/2025
1100-1205500-1215651 Brachytherapy, 60-day notices eff 3/1/2025
1100-1205500-1215651 Applied Behavior Analysis Therapy for Autism Spectrum disorder, 60-day notices eff 3/1/2025
1100-1205500-1216500 Leadless Cardiac Pacemaker, 1/1/2025, ARCHIVED: 60-day notice and policy eff 10/1/2023
|
| 4.1 | 01/13/2025 |
1100-1205500-1210902 The Orthodontic Treatment of Orofacial Anomalies policy effective 04/26/2024; ARCHIVED: policy eff 1/1/24
1100-1205500-1210906 The following policies effective 12/20/2024 have been posted:
- 3D Reconstruction; ARCHIVED: policy eff 12/15/23
- Aduhelm (Aducanumab) for Treatment of Alzheimer’s Disease; ARCHIVED: policy eff 9/22/23
- Allogeneic Pancreas Transplant; ARCHIVED: policy eff 10/27/23
- Artificial Insemination; ARCHIVED: policy eff 11/17/23
- Bariatric Surgery; ARCHIVED: policy eff
- Brexanolone; ARCHIVED: policy eff 12/15/23
- Bronchial Thermoplasty; ARCHIVED: policy eff 3/1/24
- Charged-Particle (Proton or Helium Ion) Radiation Therapy for - Neoplastic Conditions; ARCHIVED: policy eff 11/1/23
- Chimeric Antigen Receptor T-Cell Therapies for Treatment of Cancer; ARCHIVED: policy eff 10/1/203
- Clinical Trials - Routine Costs; ARCHIVED: policy eff 7/1/23, v2
- Cognitive Rehabilitation Therapy; ARCHIVED: policy eff 6/23/23
- Deep Sedation and General Anesthesia for Dental Services; ARCHIVED: policy eff 12/15/23
- Dietetic Treatment of Eating Disorders; ARCHIVED: policy eff 12/15/23
- Digital Breast Tomosynthesis (3D); ARCHIVED: policy eff 4/1/24
- Durable Medical Equipment, Prosthetics and Orthotics; ARCHIVED: policy eff 12/15/23
- Durable Medical Equipment, Prosthetics and Orthotics - Small - Group & Individual Plans, Fed 87 and QUEST Integration; ARCHIVED: policy eff 12/15/23
- Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus; ARCHIVED: policy eff 7/26/24
- Heart Transplant; ARCHIVED: policy eff 11/27/23
- Heart/Lung Transplant; ARCHIVED: policy eff 11/27/23
- Home Health Care - Commercial; ARCHIVED: policy eff 10/27/23
- Home Health Care – QUEST Integration; ARCHIVED: policy eff 10/27/23
- In Vitro Fertilization; ARCHIVED: policy eff 11/17/23
- Insulin Pumps - External; ARCHIVED: policy eff 11/17/23
- Isolated Small Bowel Transplan; ARCHIVED: policy eff 11/27/23
- Knee Orthoses for Osteoarthritis; ARCHIVED: policy eff 10/27/23
- Laser Therapy for Plaque Psoriasis; ARCHIVED: policy eff 11/17/23
- Liver Transplant and Combined Liver-Kidney Transplant; ARCHVIED: policy eff 11/17/23
- Lung and Lobar Lung Transplant; ARCHIVED: policy eff 11/17/23
- Medical Nutrition Therapy; ARCHIVED: policy eff 12/15/23
- Negative Pressure Wound Therapy (NPWT); ARCHIVED: policy eff 10/27/23
- Never Events and Hospital-Acquired Conditions; ARCHIVED: policy eff 1/1/24
- Occlusion of Uterine Arteries Using Transcatheter Embolization; ARCHIVED: policy eff 9/22/23
- Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation; ARCHIVED: policy eff 8/25/23
- Post-acute and Residential Treatment Facility Stays; ARCHIVED: policy eff 6/1/23
- Post-acute, Residential Treatment Facility and Community Care Foster Family Home Care (QI); ARCHIVED: policy eff 3/24/23
- Posterior Tibial Nerve Stimultion; ARCHIVED: policy iff 3/1/24
- Pulse Oximeter for Children; ARCHIVED: policy eff 9/22/23
- Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors; ARCHIVED: policy eff 10/27/23
- Risk-Reducing Mastectomy; ARCHIVED: policy eff 10/27/23
- Sensory Integration Therapy and Auditory Integration Therapy; ARCHIVED: policy eff 3/24/23
- Sepsis and Septic Shock (Adults); ARCHIVED: policy eff 12/15/23, v2
- Small Bowel-Liver Multivisceral Transplant; ARCHVIED: policy eff 11/27/23
- Speech Therapy Services: Rehabilitative; ARCHIVED: policy eff 12/15/23
- Spinal Cord and Dorsal Root Ganglion Stimulation; ARCHIVED: policy eff 11/17/23, v2
- Spinal Orthoses; ARCHIVED: policy eff 8/25/23
- Treatment of Hyperhydrosis; ARCHIVED: policy eff 9/22/23
- Treatment of Varicose Veins; ARCHIVED: policy eff 7/28/23
|
| 4.0 | 01/07/2025 | 1100-1205500-1209304 Posted: IV Ketamine Infusions as an Alternative to ECT, 1/1/2025, v2 |
| 3.58 (v333) | 12/30/2024 | The Bioengineered Skin and Soft Tissue Substitutes policy link has been fixed. |
| 3.57 (v332) | 12/27/2024 |
1100-956557-1205950 The following policies effective 1/1/2025 have been posted:
Cardiac Rehabilitation in the Outpatient Setting; ARCHIVED 60-day notice
Continuous Glucose Monitoring Systems (CGMS); ARCHIVED policy eff 5/1/2024
Continuous Glucose Monitoring Systems (QUEST Integration)(Policy archival)
Hip, Knee, and Shoulder Surgery; ARCHIVED policy eff 1/1/2024
Intranasal Esketamine for Major Depressive Disorder with Acute Suicidality and Treatment-Resistant Depression; ARCHIVED policy eff 3/1/2024
IV Ketamine Infusion as an Alternative to ECT; ARCHIVED 60-day notice
Precertification Requirements - HMSA Medicare Advantage Plans; ARCHIVED policy eff 1/1/2024
Spinal Interventional Pain Management and Spine Surgery; ARCHIVED policy eff 1/1/2024
Transcranial Magnetic Stimulation as a Treatment of Depression and other Psychiatric/Neurologic Disorders; ARCHIVED policy eff 6/1/2024
Transitional Concurrent Care (Policy archival)
Speech Therapy Services: Habilitative (title change). Formerly Habilitative Services; ARCHIVED 60-day notice and policy eff 12/15/2023
|
| 3.56 (v331) | 12/24/2024 |
1100-956557-1204879 The following policies have been posted:
Autonomic Nervous System Testing, 10/25/2024; ARCHIVED: policy eff 9/22/2023
Bioengineered Skin and Soft Tissue Substitutes, 10/25/2024; ARCHIVED: policy eff 10/25/2024
Breast Pumps, 8/23/2024; ARCHIVED: policy eff 8/23/2024
Catheter Ablation as Treatment for Atrial Fibrillation, 10/25/2024; ARCHIVED: policy eff 6/23/2023
Colonoscopy, 11/15/2024; ARCHIVED: policy eff 10/27/2023
Colorectal Cancer Screening, 11/15/2024; ARCHIVED: policy eff 12/01/2023
Fecal Microbiota Transplant, 10/25/2024; ARCHIVED: policy eff 4/01/2024
Glaucoma Treatments, 11/01/2024; ARCHIVED: 60-day notice and policy eff 12/01/2023
Hemophilia A and B Products, 10/25/2024; ARCHIVED: policy eff 1/1/2024
High Frequency Chest Wall Obstruction Devices and Other Airway Clearance Therapy Devices, 12/01/2024; ARCHIVED: policy eff 9/22/2023
Home Nutrition Therapy, 11/15/2024; ARCHIVED: policy eff 12/15/2023
Home Total Parenteral Nutrition for Adults, 11/15/2024; ARCHIVED: policy eff 11/17/2023
Lutathera (Lutetium 177), 10/25/2024; ARCHIVED: policy eff 9/22/2023
Luxturna (Voretigene Nepavovec-rzyl), 10/25/2024; ARCHIVED: policy eff 2/24/2023
Medical Foods for Inborn Errors of Metabolism, 11/15/2024; ARCHIVED: policy eff 11/17/2023
Observation Services, 11/15/2024; ARCHIVED: policy eff 6/23/2023
Out-of-State Air Ambulance Services, 8/23/2024; ARCHIVED: policy eff 11/01/2023
Testosterone Replacement Therapies, 10/25/2024; ARCHIVED: policy eff 1/1/2024
Total Artificial Hearts and Implantable Ventricular Assistive Devices, 10/25/2024; ARCHIVED: policy eff 9/22/2023
|
| 3.55 (v330) | 12/17/2024 |
1100-956557-1196205 Additional content updated to include HMSA Plan for Postal Service Employees.
|
| 3.54 (v329) | 12/16/2024 |
1100-956557-1196205 Content updated to include HMSA Plan for Postal Service Employees.
|
| 3.53 (v328) | 12/05/2024 |
1100-956557-1190303 Bioengineered Skin and Soft Tissue Substitutes, 10/25/2024 has been posted.
|
| 3.52 (v327) | 12/04/2024 |
1100-956557-1188452 The following 60-day notice hyperlinks have been refreshed:
Polysomnography and Home Sleep Apnea Testing
Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea
|
| 3.51 (v326) | 12/03/2024 |
1100-956557-1188452 The following 60-day notices effective 2/1/2025 have been posted:
Gender Identity Services
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea
Polysomnography and Home Sleep Apnea Testing
Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea
Speech Therapy Services: Habilitative
Transcatheter Closure of Patent Foramen Ovale for Stroke Prevention and Atrial Septal Defects
The following 60-day notices effective 1/1/2025 have been posted:
Leadless Cardiac Pacemaker
Preventive Health Guidelines - Men
Preventive Health Guidelines - Newborns and Children
Preventive Health Guidelines - Prenatal
Preventive Health Guidelines - Women
|
| 3.50 (v325) | 11/27/2024 |
1100-956552-1186618 Added a link to the Supportive Care Provider Handbook.
|
| 3.49 (v324) | 11/26/2024 |
1100-956552-1185850 Transcatheter Closure of Patent Foramen Ovale for Stroke Prevention, 60-day notice eff 2/1/25
1100-956552-1185800 Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus, eff 7/26/24; ARCHIVED: policy eff 2/24/23
|
| 3.48 (v323) | 11/25/2024 |
1100-956552-1183750 The Amniotic Membrane and Amniotic Fluid policy eff 12/01/2024 has been posted.
|
| 3.47 (v322) | 11/12/2024 |
1100-956552-1169744
The following revised 60-day notice effective 1/1/2025 has been posted:
IV Ketamine Infusions as an Alternative to Electroconvulsive Therapy (ECT), v2 (a link has been updated)
|
| 3.46 (v321) | 11/06/2024 |
1100-956552-1169744
Revised Cardiac Rehabilitative Service to Cardiac Rehabilitation in the Outpatient Setting"
|
| 3.45 (v320) | 11/05/2025 |
1100-956552-1169744
The following 60-day notices effective 1/1/2025 have been posted:
Cardiac Rehabilitative Service
IV Ketamine Infusions as an Alternative to Electroconvulsive Therapy (ECT)
|
| 3.44 (v319) | 11/04/2024 |
1100-956552-1168738 Dietetic Treatment of Eating Disorders, 12/15/2023 v2 has been posted.
|
| 3.43 (v318) | 10/02/2024 |
The following policies have been posted:
1100-956547-1150000
Compression Garments (title change), 9/1/2024; ARCHIVED: 60-day notice and policy eff 10/27/2023
Esophageal pH Monitoring, 9/1/2024; ARCHIVED: 60-day notice and policy eff 8/25/2023
Kyphoplasty and Vertebroplasty, 9/1/2024; ARCHIVED: 60-day notice and policy eff 9/1/2023
1100-956547-1150009
Extracorporeal Membrane Oxygenation (ECMO), 9/27/2024; ARCHIVED: policy eff 9/22/2023
1100-956547-1150007
Supportive Care, 10/1/2024; ARCHIVED: 60-day notice and policy eff 2/1/2024
|
| 3.42 (v317) | 09/24/2024 |
1100-956542-1144330
The following policy has been posted:
Continuous Glucose Monitoring Systems (CGMS) – Commercial Plans (title change), 5/1/2024 v2
|
| 3.41 (v316) | 09/05/2024 |
1100-956542-1129450
All Archived Change History links have been removed. The articles they each link to have been archived.
|
| 3.40 (v315) | 09/05/2024 |
1100-956542-1127804
The following 60-day notice eff 11/01/2024 has been posted:
Glaucoma Treatments
The following 60-day archival notices eff 11/01/2024 have been posted:
Extracranial Carotid Artery Stenting
Photochemotherapy
|
| 3.39 (v314) | 09/04/2024 |
1100-956542-1125812
The following policies have been posted effective 8/23/2024:
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Breast Pumps
Endovascular Procedures for Intracranial Arterial Disease
Erectile Dysfunction
Home Continuous Inotropic Infusion Therapy
Home Infusion Pain Management Therapy
Osteopathic Manipulative Treatment
Transcatheter Pulmonary Valve Implantation
|
| 3.38 (v313) | 08/19/2024 | 1100-956537-1115550
The following policy has been posted:
Bone Mineral Density, 04/01/2024, v2
|
| 3.37 (v312) | 08/12/2024 | 1100-956537-1108800
The following policy has been posted:
Gender Identity Services, 12/15/2023, v2
|
| 3.36 (v311) | 08/06/2024 | 1100-956532-1098500
The following policy has been posted:
Services Related to the COVID-19 Public Health Emergency, 7/26/2024, v2
1100-956537-1106950
The following policy has been removed.
Low-Molecular-Weight Heparin; archived as of 5/1/2024.
|
| 3.35 (v310) | 07/31/2024 | The following policies have been posted:
1100-956532-1101510
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy, 8/1/2024
1100-956532-1101512
Supportive Care, redlined 60-day notice eff 10/1/2024
|
| 3.34 (v309) | 07/30/2024 | The following policies have been posted:
1100-956532-1101504
Polysomnography and Home Sleep Apnea Testing, 2/1/2024, v2
1100-956532-1101506
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders, 6/1/2024, v3
|
| 3.33 (v308) | 07/26/2024 | 1100-956532-1098500
The following policies effective 7/26/2024 have been posted:
Complementary and Alternative Medicine (CAM)
Computer-Assisted Navigation for Orthopedic Procedure
Intravenous Anti-Microbial Therapy
Intravenous (IV) Hydration Therapy for Adults
Oxygen and Oxygen Equipment
Services Related to the COVID-19 Public Health Emergency
|
| 3.32 (v307) | 07/23/2024 | 1100-956532-1098507
The following policy has been posted:
Habilitative/Rehabilitative Physical Medicine Services, 7/1/2024, v2
|
| 3.31 (v306) | 07/16/2024 | 1100-956532-1092150
The following policy has been posted:
Hemgenix® and Roctavian® for Treatment of Congenital Hemophilia A or B, 5/1/2024 v2
|
| 3.30 (v305) | 07/03/2024 |
The following policies have been posted:
1100-956532-1081000
Compression Garments, 60-day notice eff 9/1/2024, v2
1100-956332-1086283
Radiology: Advanced Imaging Studies, 7/1/2024
|
| 3.29 (v304) | 07/02/2024 | The following policies have been posted:
1100-956532-1082900
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy, 60-day notice eff 8/1/2024, v2
1100-956532-1085350
Casgevy and Lyfgenia for the Treatment of Sickle Cell Disease, 6/1/2024, v2
Zynteglo for Treatment of B-Thalassemia, 4/1/2024, v2
|
| 3.28 (v303) | 07/01/2024 |
1100-956532-1081000
The following 60-day notices eff 9/1/2024 have been posted:
Compression Garments
Esophageal pH Monitoring
Kyphoplasty and Vertebroplasty
The following policies have been posted:
1100-956527-1080653
Reduction Mammaplasty for Breast Related Symptoms, 6/28/2024
1100-956532-1082853
Habilitative/Rehabilitative Physical Medicine Services, 7/1/2024
1100-956532-1082855
Durable Medical Equipment, Prosthetics and Orthotics (HMO, PPO), 12/15/2023, v2
Durable Medical Equipment, Prosthetics and Orthotics (Fed87,QI), 12/15/2023, v2
1100-956532-1080655
Preventive Health Guidelines - Men, 7/1/2024
Preventive Health Guidelines - Newborns and Children, 7/1/2024
Preventive Health Guidelines - Prenatal Care, 7/1/2024
Preventive Health Guidelines - Women, 7/1/2024
|
| 3.27 (v302) | 06/25/2024 | 1100-956527-1080653
The following policy has been restored:
Reduction Mammaplasty for Breast Related Symptoms, 3/24/2023
|
| 3.36 (v301) | 06/14/2024 | 1100-956527-1075303
The Chiropractic, Occupational Therapy and Physical Therapy policies are superseded by the Habilitative/Rehabilitative Physical Medicine Services. Chiropractic, Occupational Therapy, and Physical Therapy. The Chiropractic, Occupational Therapy and Physical Therapy policy links and line items have been updated for clarity. |
| 3.35 (v300) | 06/07/2024 |
1100-956527-1071519
The following policy has been posted:
Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder, 11/1/2023, v2
1100-956527-1071517
The following policy has been posted:
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric-Neurologic Disorders, 6/1/2024 v2 (formatting update)
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| 3.34 (v299) | 06/03/2024 | 1100-956527-1058807
The following new policies have been posted:
Casgevy® (Exagamglogene Autotemcel) and Lyfgenia® (Lovotibeglogene autotemcel) for Treatment of Sickle Cell Disease, 6/1/2024
Vyjuvek® (Beremagene geperpavec-svdt) for Treatment of Wounds in Dystrophic Epidermolysis Bullosa, 6/1/2024
1100-956527-1058810
The following polices have been posted:
Hepatic Elastography for Chronic Liver Disease, 6/1/2024; ARCHIVED: policy eff 12/16/2022
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders, 6/1/2024; ARCHIVED: 60-day notice and policy eff 5/26/2023, v2
Habilitative/Rehabilitative Physical Medicine Services: Chiropractic, Occupational Therapy, and Physical Therapy, 6/1/2024 (new); ARCHIVED: 60-day notic
1100-956527-1058814
The following policies have been archived as of 6/1/2024:
Chiropractic Services
Occupational Therapy
Physical Therapy
Subcutaneous Implantable Cardioverter Defibrillator (ICD) System
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| 3.33 (v298) | 05/24/2024 |
1100-956522-1058805
The following 60-day notice has been posted:
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy, eff 8/1/2024
1100-956522-1058801
The following policies have been posted:
Cosmetic and Reconstructive Surgery and Services, 5/24/2024; ARCHIVED policy eff 9/22/2023
Corneal Collagen Cross-Linking, 5/24/2024; ARCHIVED policy eff 5/26/2023
Readmissions and Transfers, 5/24/2024; ARCHIVED policy eff 6/23/2023
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| 3.32 (v297) | 05/23/2024 | 1100-956522-1059422
Added a link to the Habilitative/Rehabilitative Physical Medicine Services: Chiropractic, Occupational Therapy, and Physical Therapy Coding Guidelines. |
| 3.31 (v296) | 05/22/2024 | 1100-956522-1059420
The following policy has been posted:
Vyjuvek® (Beremagene geperpavec-svdt) for Treatment of Wounds in Dystrophic Epidermolysis Bullosa, 60-day notice eff 6/1/2024, v2.; added link to archived folder. |
| 3.30 (v295) | 05/16/2024 | 1100-956522-1055850
The following policy has been posted:
Deep Sedation and General Anesthesia for Dental Services, 11/17/2023, v3 (formatting note was added to the policy history - policy statement remains unchanged); archived policy eff 11/17/2023, v2
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| 3.29 (v294) | 05/15/2024 | 1100-956522-1055850
The following policy has been posted:
Deep Sedation and General Anesthesia for Dental Services, 11/17/2023, v2; archived policy eff 11/17/2023
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| 3.28 (v293) | 05/13/2024 | 1100-956522-1053150
The following policy has been posted:
Spinal Cord and Dorsal Root Ganglion Stimulation, 11/27/2023, v2
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| 3.27 (v292) | 05/08/2024 | 1100-956522-1048953
The following policies have been posted:
Home Nutrition Therapy, 12/15/2023; Archived: policy eff 5/1/2022
Services Related to the COVID-19 Public Health Emergency, 2/1/2024; Archived: 60-day notice and policy eff 8/1/2023
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| 3.26 (v291) | 05/02/2024 | 1100-956517-1043100
The following policies have been posted:
Transcatheter Aortic-Valve Implantation for Aortic Stenosis, 4/25/2024, v2
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| 3.25 (v290) | 04/30/2024 | 1100-956517-1043600
The following policy has been posted:
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome, 3/22/2024; ARCHIVED: policy eff 3/24/2023
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| 3.24 (v289) | 04/29/2024 | 1100-956517-1043205
The following policies have been posted:
Continuous Glucose Monitoring Systems - QUEST Integration, 5/1/2024; archived 60-day notice
Continuous Glucose Monitoring Systems (CGMS) – Commercial Plans (title change), 5/1/2024; archived 60-day notice and policy eff 1/1/2023
Hemgenix® (Etranacogene dezaparvovec-drlb) and Roctavian® (Valoctocogene roxaparvovec-rvox) for Treatment of Congenital Hemophilia A or B, 5/1/2024; archived 60-day notice
Low-Molecular-Weight Heparin, 5/1/2024; archived policy eff 4/1/2024
1100-956517-1043200
The following redlined 60-day notices eff 7/1/2024 have been posted:
Preventive Health Guidelines - Men
Preventive Health Guidelines - Newborns and Children
Preventive Health Guidelines - Prenatal
Preventive Health Guidelines - Women
1100-956517-1043100
The following policies have been posted:
Transcatheter Aortic-Valve Implantation for Aortic Stenosis, 4/25/2024; archived policy eff 5/26/2023, v2
Vagus Nerve Stimulation, 4/26/2024; archived policy eff 5/26/2023
Orthodontic Treatment of Orofacial Anomalies, 1/1/2024: archived policy eff 9/22/23
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| 3.23 (v288) | 04/12/2024 | The following policy has been posted:
Transitional Concurrent Care, 1/1/2024; Archived policy eff 1/1/2023
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| 3.22 (v287) | 04/03/2024 | The following policies which were archived effective 2/1/2024 have been removed from the table. To access the archived policies, please refer to the Medical Policies - ARCHIVED article.
Surgical Treatment of Femoroacetabular Impingement
Zevalin (Ibritumomab tiuxetan)
The Subcutaneous Implantable Cardioverter Defibrillator (ICD) System redline 60-day archival notice effective 6/1/2024 has been posted.
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| 3.21 (v286) | 04/02/2024 | The following policy has been posted:
Hemgenix® (Etranacogene dezaparvovec-drlb) and Roctavian® (Valoctocogene roxaparvovec-rvox) for Treatment of Congenital Hemophilia A or B, 60-day notice effective 5/1/2024
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| 3.20 (v285) | 04/01/2024 | The following policies have been posted and redlines archived:
Preventive Health Guidelines - Men, 01/01/2024 corrections final
Preventive Health Guidelines - Newborns and Children, 01/01/2024 corrections final
Preventive Health Guidelines - Prenatal Care, 01/01/2024 corrections final
Preventive Health Guidelines - Women, 01/01/2024 corrections final
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| 3.19 (v284) | 03/28/2024 |
The following 60-day notices eff 6/1/2024 have been posted:
Casgevy® (Exagamglogene Autotemcel)and Lyfgenia® (Lovotibeglogene autotemcel) for the Treatment of Sickle Cell Disease (new)
Chiropractic Services (archival notice)
Habilitative/Rehabilitative Physical Medicine Services: Chiropractic, Occupational Therapy, and Physical Therapy (new)
Hepatic Elastography for Chronic Liver Disease (redlined)
Occupational Therapy (archival notice)
Physical Therapy (archival notice)
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders (redlined)
Vyjuvek® (Beremagene geperpavec-svdt) for Treatment of Wounds in Dystrophic Epidermolysis Bullosa (new)
The following policies, effective 4/1/2024, have been posted.
Amvuttra® (Vutrisiran) and Onpattro® (Patisiran) for Hereditary Transthyretin-Mediated Amyloidosis in Adults
Bone (Mineral) Density Studies, archived policy eff 12/16/2022
Cardiac-Related Procedures, archived policy eff 4/1/2023
Digital Breast Tomosynthesis (3D), archived policy eff 11/18/2022
Fecal Microbiota Transplantation, archived policy eff 3/1/2023, v2
Givlaari® (Givosiran) for the Treatment of Acute Hepatic Porphyria
Low-Molecular-Weight Heparin, archived policy eff 12/16/2022
Oxlumo® (Lumasiran) for Treatment of Primary Hyperoxaluria Type 1
Radiology: Advanced Imaging Studies, archived policy eff 4/1/2023
Zolgensma® (Onasemnogene Abeparvovec-xioi) for Spinal Muscular Atrophy, archived policy eff 9/22/2023
Zynteglo® (Betibeglogene autotemcel) for Treatment of β-Thalassemia
The following policies effective 3/22/2024 have been posted. ARCHVIED: Policies effective 3/24/2023, except where noted.
Allogeneic Hematopoietic SCT for Genetic Diseases and Acquried Anemias
Allogeneic Hematopoietic SCT for Myelodysplastic Syndromes and Myeloproliferative neoplasms
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
Hematopoietic Cell Transplantation for Autoimmune Diseases
Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
*NAME CHANGE* Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia (previously: Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia)
Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma
Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
Hematopoietic Cell Transplantation for Hodgkin Lymphoma
Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas; archived policy eff 7/1/2023
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
Hematopoietic Cell Transplantation for Primary Amyloidosis
Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia
Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors
Hematopoietic Stem Cell Transplantation for Solid Tumors of Childhood
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| 3.18 | 03/19/2024 | The following policy has been posted:
Bariatric Surgery, 3/1/2024, v2 (formatting updates); archived policy eff 3/1/2024 (v1)
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| 3.17 (v283) | 03/18/2024 | The following policies have been posted:
Clinical Trials - Routine Costs, 7/1/2023, v2
Image-Guided Radiation Therapy (IGRT), 3/1/2024; archived policy eff 3/1/2023
Updated Hemophilia A and B Blood Products to Hemophilia A and B Products
Updated the Posterior Tibial Nerve Stimulation effective date to 3/1/2024.
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3.16 (v281)
(v282) | 03/14/2024 | The following policies have been posted:
Bariatric Surgery, 3/1/2024; archived policy eff 1/1/2023
Bronchial Thermoplasty, 3/1/2024; archived policy eff 12/16/2022
Intranasal Esketamine for Major Depressive Disorder with Acute Suicidality and Treatment-Resistant Depression *NAME CHANGE* previously Esketamine Nasal Spray for Treatment-Resistant Depression, 3/1/2024; archived policy eff 4/1/2023
Posterior Tibial Nerve Stimulation, 3/1/2024; archived policy eff 9/23/2022
Hemophilia A and B Products, 1/1/2024; archived policy eff 7/1/2023 and 60-day notice eff 1/1/24
Hip Knee and Shoulder Surgery, 1/1/2024; archived policy eff 9/22/23 and 60-day notice eff 1/1/24
Supportive Care, 2/1/2024; archived policy eff 1/1/23 and 60-day notice eff 2/1/24
Continuous Glucose Monitoring System (CGMS) - Commercial Plans, redlined 60-day notice eff 5/1/2024
Continuous Glucose Monitoring System (CGMS) - QUEST Integration, 60-day notice eff 5/1/2024
Hematopoietic Cell Transplantation for Primary Amyloidosis, 3/24/2023, v3 - no policy change; updated metadata only.
Spinal Interventional Pain Management and Spine Surgery 1/1/2024; archived policy eff 1/1/23 and 60-day notice eff 1/1/24
The 60-day notice for Low-Molecular-Weight Heparin link was updated to 60-day archival notice eff 4/1/2024.
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| 3.15 (v280) | 03/13/2024 | Sepsis and Septic Shock - Adults, 12/15/2023, v2 has been posted. |
| 3.14 (v279) | 03/05/2024 | Zevalin (Ibritumomab Tiuxetan) policy has been archived as of 2/1/2024. Links have been updated as applicable. |
| 3.13 (v278) | 02/28/2024 | The following policies have been posted:
Preventive Health Guidelines - Men, 01/01/2024; January corrections eff 1/1/24
Preventive Health Guidelines - Newborns and Children, 01/01/2024; January corrections eff 1/1/24
Preventive Health Guidelines - Prenatal Care, 01/01/2024; January corrections eff 1/1/24
Preventive Health Guidelines - Women, 01/01/2024; January corrections eff 1/1/24
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| 3.12 (v277) | 02/27/2024 | The following has been posted:
Digital Breast Tomosynthesis (3D), redline 60-day notice eff 4/1/2024
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| 3.11 (v276) | 02/23/2024 |
The following policies have been posted:
Blepharoplasty and Repair of Blepharoptosis, 2/23/2024; ARCHIVED policy eff 4/28/2023
Panniculectomy Abdominoplasty, 2/23/2024; ARCHIVED policy eff 2/24/2023
Photodynamic Therapy for the Treatment of Actinic Keratoses and Other Skin Lesions, 2/23/2024; ARCHIVED policy eff 2/24/2023
Redlined 60-day notices effective 4/1/2024 have been posted for the following policies:
Cardiac-Related Procedures
Radiology, Advanced Imaging Studies
Zolgensma® (Onasemnogene Abeparvovec-xioi) for Spinal Muscular Atrophy - This policy has been unarchived. Current policy eff 9/22/2023 has been reposted.
60-day notices eff 4/1/2024 have been posted for the following new policies:
Amvuttra® (Vutrisiran) and Onpattro® (Patisiran) for Hereditary Transthyretin-Mediated Amyloidosis in Adults
Givlaari® (Givosiran) for the Treatment of Acute Hepatic Porphyria
Oxlumo® (Lumasiran) for Treatment of Primary Hyperoxaluria Type 1
Zynteglo® (Betibeglogene autotemcel) for Treatment of β-Thalassemia
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| 3.10 (v275) | 02/22/2024 | The following policy has been posted:
Bone (Mineral) Density Studies, redline 60-day notice eff 4/1/2024
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| 3.9 (v274) | 02/14/2024 |
The following policies have been posted:
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, 2/1/2024; ARCHIVED: 60-day notice eff 2/1/2024.
Polysomnograpy and Home Sleep Apnea Testing, 2/1/2024; ARCHIVED: 60-day notice eff 2/1/2024 and policy eff 8/1/2022, v3.
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| 3.8 (v273) | 02/07/2024 | The following policy has been posted:
Fecal Microbiota Transplantation, redlined 60-day notice eff 4/1/2024
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| 3.7 (v272) | 02/05/2024 | The following policies have been archived effective 2/1/2024:
Surgical Treatment of Femoroacetabular Impingement
Zevalin (Ibritumomab Tiuxetan)
|
| 3.6 (v271) | 01/29/2024 | The following archived policies have bee removed from the policy table:
Anesthesia Services for Gastrointestinal Endoscopic Procedures
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)
Computerized Corneal Topography
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
Kymriah (tisagenlecleucel)
Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk
Molecular Markers in Fine Needle Aspirates of the Thyroid
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Preimplantation Genetic Testing (PGT)
Prenatal Carrier Screening for Genetic Diseases
Tecartus (Brexucabtagene Autoleucel)
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
Yescarta (Axicabtagene Ciloleucel)
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| 3.5 (v270) | 01/24/2024 | The following policy has been posted:
Glaucoma Treatments (Formerly: Micro-Invasive Glaucoma Surgery), 12/1/2023. Archived policy eff 2/25/2022 and 60-day notice eff 12/1/2023. Moved policy from table section M to section G.
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| 3.4 (v269) | 01/19/2024 | An Avalon Healthcare Solutions disclosure statement has been added. |
| 3.3 (v268) | 01/11/2024 | The following policies were posted:
Occupational Therapy, 1/1/2023, v2; updated Evolent link in the Additional Information column
Physical Therapy, 1/1/2023, v2; updated Evolent link in the Additional Information column
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| 3.2 (v267) | 01/09/2024 | The following policy has been archived:
Fecal Microbiota Transplant, redline 60-day notice eff 12/1/2023
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| 3.1 (v266) | 01/02/2024 | The following policies have been posted:
Bariatric Surgery, redlined 60-day notice, eff 3/1/2024
Bronchial Thermoplasty, redlined 60-day notice, eff 3/1/2024
Esketamine Nasal Spray for Treatment Resistant Depression, redlined 60-day notice, eff 3/1/2024
Low-Molecular-Weight Heparin, redlined 60-day notice, eff 4/1/2024
Posterior Tibial Nerve Stimulation, redlined 60-day notice, eff 3/1/2024
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