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  1. Home
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  6. Medical

Medical Policies - Medical

  • Apheresis Commercial - Medical 128

    PDF, 291 KBLast Updated: 07/02/2025

    PDF, 291 KBLast Updated: 07/02/2025

  • Apheresis Medicaid - Medical 128

    PDF, 295 KBLast Updated: 07/02/2025

    PDF, 295 KBLast Updated: 07/02/2025

  • Autologous Myoblast and Muscle Cell Injection Commercial - Medical 262

    PDF, 246 KBLast Updated: 05/12/2025

    PDF, 246 KBLast Updated: 05/12/2025

  • Autologous Myoblast and Muscle Cell Injection Medicaid - Medical 262

    PDF, 224 KBLast Updated: 05/12/2025

    PDF, 224 KBLast Updated: 05/12/2025

  • Automated Nerve Conduction Testing Commercial - Medical 250

    PDF, 277 KBLast Updated: 05/12/2025

    PDF, 277 KBLast Updated: 05/12/2025

  • Automated Nerve Conduction Testing Medicaid - Medical 250

    PDF, 298 KBLast Updated: 05/12/2025

    PDF, 298 KBLast Updated: 05/12/2025

  • Bone Scaffolding Commercial - Medical 02

    PDF, 241 KBLast Updated: 01/02/2026

    PDF, 241 KBLast Updated: 01/02/2026

  • Bone Scaffolding Medicaid - Medical 02

    PDF, 290 KBLast Updated: 01/02/2026

    PDF, 290 KBLast Updated: 01/02/2026

  • Category III codes Commercial - Medical 336

    PDF, 450 KBLast Updated: 01/02/2026

    PDF, 450 KBLast Updated: 01/02/2026

  • Category III codes Medicaid - Medical 336

    PDF, 451 KBLast Updated: 01/02/2026

    PDF, 451 KBLast Updated: 01/02/2026

  • Chemotherapy and Supportive Care Commercial Medical 316

    PDF, 305 KBLast Updated: 12/29/2025

    PDF, 305 KBLast Updated: 12/29/2025

  • Chemotherapy and Supportive Care Medicaid Medical 316

    PDF, 308 KBLast Updated: 12/29/2025

    PDF, 308 KBLast Updated: 12/29/2025

  • Chemotherapy and Supportive Care Medicare - Medical 316

    PDF, 325 KBLast Updated: 01/13/2026

    PDF, 325 KBLast Updated: 01/13/2026

  • Chiropractic Services Commercial - Medical 182

    PDF, 381 KBLast Updated: 08/01/2025

    PDF, 381 KBLast Updated: 08/01/2025

  • Dry Hydrotherapy Commercial - Medical 267

    PDF, 218 KBLast Updated: 05/12/2025

    PDF, 218 KBLast Updated: 05/12/2025

  • Dry Hydrotherapy Medicaid - Medical 267

    PDF, 270 KBLast Updated: 05/12/2025

    PDF, 270 KBLast Updated: 05/12/2025

  • Dry Needling Commercial - Medical 173

    PDF, 251 KBLast Updated: 07/02/2025

    PDF, 251 KBLast Updated: 07/02/2025

  • Dry Needling Medicaid - Medical 173

    PDF, 258 KBLast Updated: 07/02/2025

    PDF, 258 KBLast Updated: 07/02/2025

  • Electric Stimulation Commercial - Medical 349

    PDF, 409 KBLast Updated: 02/06/2026

    PDF, 409 KBLast Updated: 02/06/2026

  • Electric Stimulation Medicaid-Medical 349

    PDF, 414 KBLast Updated: 02/06/2026

    PDF, 414 KBLast Updated: 02/06/2026

  • Enteral and Parenteral Feeding and Intradialytic Parenteral Nutrition Commercial - Medical 13

    PDF, 296 KBLast Updated: 05/12/2025

    PDF, 296 KBLast Updated: 05/12/2025

  • Enteral and Parenteral Feeding and Intradialytic Parenteral Nutrition Medicaid - Medical 13

    PDF, 327 KBLast Updated: 05/15/2025

    PDF, 327 KBLast Updated: 05/15/2025

  • Eustachian tube balloon dilation (ETBD) Tuboplasty Commercial - Medical 328

    PDF, 278 KBLast Updated: 05/12/2025

    PDF, 278 KBLast Updated: 05/12/2025

  • Eustachian tube balloon dilation (ETBD) Tuboplasty Medicaid - Medical 328

    PDF, 281 KBLast Updated: 05/12/2025

    PDF, 281 KBLast Updated: 05/12/2025

  • Eustachian tube balloon dilation (ETBD) Tuboplasty Medicare - Medical 328

    PDF, 324 KBLast Updated: 05/15/2025

    PDF, 324 KBLast Updated: 05/15/2025

  • Fetal Magnetic Cardiac Signal Commercial - Medical 297

    PDF, 192 KBLast Updated: 09/02/2025

    PDF, 192 KBLast Updated: 09/02/2025

  • Fetal Magnetic Cardiac Signal Medicaid -Medical 297

    PDF, 215 KBLast Updated: 09/02/2025

    PDF, 215 KBLast Updated: 09/02/2025

  • Fetal Magnetic Cardiac Signal Medicare - Medical 297

    PDF, 217 KBLast Updated: 09/02/2025

    PDF, 217 KBLast Updated: 09/02/2025

  • Gait analysis and surface electromyography Commercial - Medical 345.pdf

    PDF, 207 KBLast Updated: 01/02/2026

    PDF, 207 KBLast Updated: 01/02/2026

  • Gait Analysis and Surface Electromyography Medicaid - Medical 345.pdf

    PDF, 253 KBLast Updated: 01/02/2026

    PDF, 253 KBLast Updated: 01/02/2026

  • Gait Analysis and Surface Electromyography Medicare - Medical 345.pdf

    PDF, 257 KBLast Updated: 01/02/2026

    PDF, 257 KBLast Updated: 01/02/2026

  • Gastrointestinal Capsule Endoscopy Commercial - Medical 81

    PDF, 258 KBLast Updated: 10/23/2025

    PDF, 258 KBLast Updated: 10/23/2025

  • Gastrointestinal Capsule Endoscopy Medicaid - Medical 81

    PDF, 255 KBLast Updated: 10/23/2025

    PDF, 255 KBLast Updated: 10/23/2025

  • Home Health Aide Commercial - Medical 144

    PDF, 228 KBLast Updated: 01/02/2026

    PDF, 228 KBLast Updated: 01/02/2026

  • Home Health Aide Medicaid - Medical 144

    PDF, 231 KBLast Updated: 01/02/2026

    PDF, 231 KBLast Updated: 01/02/2026

  • Immunoglobulin Light Chains Medicaid - Medical 333

    PDF, 234 KBLast Updated: 12/29/2025

    PDF, 234 KBLast Updated: 12/29/2025

  • Immunoglobulin Light Chains Medicare - Medical 333

    PDF, 221 KBLast Updated: 12/29/2025

    PDF, 221 KBLast Updated: 12/29/2025

  • Implantable Hemodynamic Monitoring for Heart Failure Commercial - Medical 317

    PDF, 255 KBLast Updated: 12/01/2025

    PDF, 255 KBLast Updated: 12/01/2025

  • Implantable Hemodynamic Monitoring for Heart Failure Medicaid - Medical 317

    PDF, 277 KBLast Updated: 12/01/2025

    PDF, 277 KBLast Updated: 12/01/2025

  • Ingestible Devices Commercial - Medical 344

    PDF, 196 KBLast Updated: 01/02/2026

    PDF, 196 KBLast Updated: 01/02/2026

  • Ingestible Devices Medicaid Medical 344.pdf

    PDF, 247 KBLast Updated: 01/02/2026

    PDF, 247 KBLast Updated: 01/02/2026

  • Ingestible Devices Medicare - Medical 344

    PDF, 248 KBLast Updated: 01/02/2026

    PDF, 248 KBLast Updated: 01/02/2026

  • Injectable Fillers & Bulking Agents Commercial - Medical 153

    PDF, 244 KBLast Updated: 01/19/2026

    PDF, 244 KBLast Updated: 01/19/2026

  • Injectable Fillers & Bulking Agents Medicaid - Medical 153

    PDF, 268 KBLast Updated: 01/19/2026

    PDF, 268 KBLast Updated: 01/19/2026

  • Intensive Cardiac Rehabilitation Programs Commercial - Medical 52

    PDF, 275 KBLast Updated: 06/04/2025

    PDF, 275 KBLast Updated: 06/04/2025

  • Intensive Cardiac Rehabilitation Programs Medicaid - Medical 52

    PDF, 307 KBLast Updated: 06/04/2025

    PDF, 307 KBLast Updated: 06/04/2025

  • Intra-arterial (IA) Chemotherapy Commercial - Medical 254

    PDF, 316 KBLast Updated: 05/12/2025

    PDF, 316 KBLast Updated: 05/12/2025

  • Intra-arterial (IA) Chemotherapy Medicaid - Medical 254

    PDF, 286 KBLast Updated: 05/12/2025

    PDF, 286 KBLast Updated: 05/12/2025

  • Keratoconus Lenses and Interventions-Piggyback Contact Lenses Commercial - Medical 03

    PDF, 289 KBLast Updated: 06/04/2025

    PDF, 289 KBLast Updated: 06/04/2025

  • Keratoconus Lenses and Interventions-Piggyback Contact Lenses Medicaid - Medical 03

    PDF, 282 KBLast Updated: 12/26/2025

    PDF, 282 KBLast Updated: 12/26/2025

  • Level of Care Guidance for Observation vs Inpatient Hospital Stays Commercial - Medical 350

    PDF, 229 KBLast Updated: 10/27/2025

    PDF, 229 KBLast Updated: 10/27/2025

  • Level of Care Guidance for Observation vs Inpatient Hospital Stays Medicaid - Medical 350

    PDF, 258 KBLast Updated: 10/27/2025

    PDF, 258 KBLast Updated: 10/27/2025

  • Long-Term Care Hospital (LTACH) Services Medicaid - Medical 337

    PDF, 316 KBLast Updated: 07/02/2025

    PDF, 316 KBLast Updated: 07/02/2025

  • Long-Term Care Hospital (LTACH) Services s Medicare Medical 337.pdf

    PDF, 311 KBLast Updated: 12/29/2025

    PDF, 311 KBLast Updated: 12/29/2025

  • Medical Necessity Guidelines Commercial - Medical 347

    PDF, 229 KBLast Updated: 01/02/2026

    PDF, 229 KBLast Updated: 01/02/2026

  • Mobile Cardiac Telemetry Commercial - Medical 112

    PDF, 256 KBLast Updated: 07/02/2025

    PDF, 256 KBLast Updated: 07/02/2025

  • Mobile Cardiac Telemetry Medicaid - Medical 112

    PDF, 280 KBLast Updated: 07/02/2025

    PDF, 280 KBLast Updated: 07/02/2025

  • Muscle Pain Detector Commercial - Medical 247

    PDF, 195 KBLast Updated: 12/29/2025

    PDF, 195 KBLast Updated: 12/29/2025

  • Muscle Pain Detector Medicaid - Medical 247

    PDF, 225 KBLast Updated: 12/29/2025

    PDF, 225 KBLast Updated: 12/29/2025

  • Nonemergent Ambulance Services Commercial - Medical 105

    PDF, 294 KBLast Updated: 08/19/2025

    PDF, 294 KBLast Updated: 08/19/2025

  • Nonemergent Ambulance Services Medicaid - Medical 105

    PDF, 312 KBLast Updated: 06/04/2025

    PDF, 312 KBLast Updated: 06/04/2025

  • Not Medically Necessary, Experimental, Investigational and Unproven Guidelines Commercial - Medical 348

    PDF, 249 KBLast Updated: 01/19/2026

    PDF, 249 KBLast Updated: 01/19/2026

  • Phase II Cardiac Rehabilitation Commercial - Medical 51

    PDF, 304 KBLast Updated: 06/04/2025

    PDF, 304 KBLast Updated: 06/04/2025

  • Phase II Cardiac Rehabilitation Medicaid - Medical 51

    PDF, 279 KBLast Updated: 06/04/2025

    PDF, 279 KBLast Updated: 06/04/2025

  • Physical Therapy for Treating Obesity Commercial - Medical 252

    PDF, 295 KBLast Updated: 05/14/2025

    PDF, 295 KBLast Updated: 05/14/2025

  • Physical Therapy for Treating Obesity Medicaid - Medical 252

    PDF, 297 KBLast Updated: 05/14/2025

    PDF, 297 KBLast Updated: 05/14/2025

  • Physical Therapy for Treating Obesity Medicare - Medical 252

    PDF, 268 KBLast Updated: 05/15/2025

    PDF, 268 KBLast Updated: 05/15/2025

  • Platelet Rich-Plasma Commercial - Medical 246

    PDF, 327 KBLast Updated: 05/12/2025

    PDF, 327 KBLast Updated: 05/12/2025

  • Platelet Rich-Plasma Medicaid - Medical 246

    PDF, 316 KBLast Updated: 05/12/2025

    PDF, 316 KBLast Updated: 05/12/2025

  • Sepsis and Other Febrile Illness, Observation Care Medicaid Medical 346 OBS

    PDF, 240 KBLast Updated: 01/02/2026

    PDF, 240 KBLast Updated: 01/02/2026

  • Sepsis and Other Febrile Illness, Observation Care Medical 346 OBS

    PDF, 241 KBLast Updated: 01/02/2026

    PDF, 241 KBLast Updated: 01/02/2026

  • Sepsis and Other Febrile Illness, without Focal Infection Commercial Medical 346

    PDF, 240 KBLast Updated: 01/02/2026

    PDF, 240 KBLast Updated: 01/02/2026

  • Sepsis and Other Febrile Illness, without Focal Infection Medicaid Medical 346

    PDF, 239 KBLast Updated: 01/02/2026

    PDF, 239 KBLast Updated: 01/02/2026

  • Transarterial Embolization Direct Therapies (TAE, TACE and DEB-TACE) Commercial - Medical 139

    PDF, 319 KBLast Updated: 05/14/2025

    PDF, 319 KBLast Updated: 05/14/2025

  • Transarterial Embolization Direct Therapies (TAE, TACE and DEB-TACE) Medicaid - Medical 139

    PDF, 310 KBLast Updated: 05/12/2025

    PDF, 310 KBLast Updated: 05/12/2025

  • Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Commercial - Medical 256

    PDF, 262 KBLast Updated: 06/04/2025

    PDF, 262 KBLast Updated: 06/04/2025

  • Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Medicaid - Medical 256

    PDF, 298 KBLast Updated: 06/04/2025

    PDF, 298 KBLast Updated: 06/04/2025

  • Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Medicare - Medical 256

    PDF, 294 KBLast Updated: 02/11/2026

    PDF, 294 KBLast Updated: 02/11/2026

  • Urinary Incontinence Treatments Commercial - Medical 130

    PDF, 232 KBLast Updated: 01/02/2026

    PDF, 232 KBLast Updated: 01/02/2026

  • Urinary Incontinence Treatments Medicaid - Medical 130

    PDF, 258 KBLast Updated: 01/02/2026

    PDF, 258 KBLast Updated: 01/02/2026

  • Vestibular Evoked Myogenic Potential (VEMP) Commercial - Medical 174

    PDF, 293 KBLast Updated: 05/12/2025

    PDF, 293 KBLast Updated: 05/12/2025

  • Vestibular Evoked Myogenic Potential (VEMP) Medicaid - Medical 174

    PDF, 294 KBLast Updated: 05/12/2025

    PDF, 294 KBLast Updated: 05/12/2025

  • Vision Therapy for Convergence Insufficiency Commercial - Medical 324

    PDF, 253 KBLast Updated: 08/01/2025

    PDF, 253 KBLast Updated: 08/01/2025

  • Vision Therapy for Convergence Insufficiency Medicaid - Medical 324

    PDF, 284 KBLast Updated: 12/29/2025

    PDF, 284 KBLast Updated: 12/29/2025

  • Vision Therapy for Convergence Insufficiency Medicare Medical 324

    PDF, 302 KBLast Updated: 12/29/2025

    PDF, 302 KBLast Updated: 12/29/2025

  • Wearable Monitoring and Treatment Devices Commercial Medical 259

    PDF, 279 KBLast Updated: 08/01/2025

    PDF, 279 KBLast Updated: 08/01/2025

  • Wearable Monitoring and Treatment Devices Medicaid Medical 259

    PDF, 283 KBLast Updated: 08/01/2025

    PDF, 283 KBLast Updated: 08/01/2025

  • Wound Treatment Commercial - Medical 343

    PDF, 284 KBLast Updated: 09/02/2025

    PDF, 284 KBLast Updated: 09/02/2025

  • Wound Treatment Medicaid - Medical 343

    PDF, 293 KBLast Updated: 09/02/2025

    PDF, 293 KBLast Updated: 09/02/2025

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© Sentara Health Plans 2026, PO Box 66189, Virginia Beach, Virginia 23466

Sentara Health Plans is the trade name for Sentara Health Plans, Sentara Health Insurance Company, Sentara Health Administration, Inc., and Sentara Behavioral Health Services, Inc. Vantage Health Maintenance Organization (HMO) and Point of Service (POS) plans are issued and underwritten by Sentara Health Plans. Medicare products are administered under an agreement with Sentara Health Plans and the Centers for Medicare and Medicaid Services (CMS). Medicaid and Family Access to Medical Insurance Security (FAMIS) products are administered under an agreement with Sentara Health Plans and the Virginia Department of Medical Assistance Services (DMAS). Plus Preferred Provider Organization (PPO) products are issued and underwritten by Sentara Health Insurance Company. The Sentara Employee Assistance Program (EAP) is administered by Sentara Behavioral Health Services, Inc. Large group self-funded health plans and BusinessEDGE® plans are administered but not underwritten by Sentara Health Administration, Inc. Wellness programs are administered by Sentara Health Administration, Inc. All plans have benefit exclusions and limitations, and terms under which the policy or plan may be continued in force or discontinued. For costs and complete details of coverage, please call your broker or review this website for more information. Sentara Health Plans complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.