Medical Policies - Medical

Accelerated Partial Breast Irradiation Commercial - Medical 207

Accelerated Partial Breast Irradiation Medicaid - Medical 207

Apheresis Commercial - Medical 128

Apheresis Medicaid - Medical 128

Apixaban (Eliquis) Drug Level Commercial - Medical 303

Apixaban (Eliquis) Drug Level Medicaid - Medical 303

Apixaban (Eliquis) Drug Level Medicare - Medical 303

Archived - Genetic Testing - Cancer Prevention, Diagnosis and Treatment Commercial - Medical 34A

Archived - Genetic Testing - Cancer Prevention, Diagnosis and Treatment Medicaid - Medical 34A

Archived - Genetic Testing - Cancer Prevention, Diagnosis and Treatment Medicare - Medical 34A

Archived - Genetic Testing - Cardioneurovascular and Developmental Diagnosis Commercial - Medical 34C

Archived - Genetic Testing - Cardioneurovascular and Developmental Diagnosis Medicaid - Medical 34C

Archived - Genetic Testing - Cardioneurovascular and Developmental Diagnosis Medicare - Medical 34C

Archived - Genetic Testing - Pharmacogenetic Testing Commercial - Medical 34E

Archived - Genetic Testing - Pharmacogenetic Testing Medicaid - Medical 34E

Archived - Genetic Testing - Pharmacogenetic Testing Medicare - Medical 34E.pdf

Archived - Genetic Testing - Preconceptional-Prenatal-Preimplantation Commercial - Medical 34D

Archived - Genetic Testing - Preconceptional-Prenatal-Preimplantation Medicaid - Medical 34D

Archived - Genetic Testing - Preconceptional-Prenatal-Preimplantation Medicare - Medical 34D

Archived - Genetic Testing - Pre-Treatment or Post-Intervention Commercial - Medical 34B

Archived - Genetic Testing - Pre-Treatment or Post-Intervention Medicaid - Medical 34B

Archived - Genetic Testing - Pre-Treatment or Post-Intervention Medicare - Medical 34B

Autologous Myoblast and Muscle Cell Injection Commercial - Medical 262

Autologous Myoblast and Muscle Cell Injection Medicaid - Medical 262

Autologous Serum Tears Commercial - Medical 244

Autologous Serum Tears Medicaid - Medical 244

Autologous Serum Tears Medicare - Medical 244

Automated Nerve Conduction Testing Commercial - Medical 250

Automated Nerve Conduction Testing Medicaid - Medical 250

Bone Scaffolding Commercial - Medical 02

Bone Scaffolding Medicaid - Medical 02

Brachytherapy Commercial - Medical 71

Brachytherapy Medicaid - Medical 71

Bulking Agents for Vocal Cord Insufficiency Commercial - Medical 153

Bulking Agents for Vocal Cord Insufficiency Medicaid - Medical 153

Bulking Agents for Vocal Cord Insufficiency Medicare - Medical 153

Category III codes Commercial - Medical 336

Category III codes Medicaid - Medical 336

Cell Enumeration Commercial - Medical 310

Cell Enumeration Medicaid - Medical 310

Chemotherapy and Supportive Care Commercial Medical 316

Chemotherapy and Supportive Care Medicaid Medical 316

Chemotherapy and Supportive Care Medicare Medical 316

Chiropractic Services Commercial - Medical 182

Commercial Category III codes Medical 336

Commercial Medical Necessity Guidelines Medical 347

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

Dry Hydrotherapy Commercial - Medical 267

Dry Hydrotherapy Medicaid - Medical 267

Dry Needling Commercial - Medical 173

Dry Needling Medicaid - Medical 173

Early Inpatient Admission Commercial - Medical 145

Early Inpatient Admission Medicaid - Medical 145

Electric Cell-Signaling Energy Waves (EcST and ESI) Commercial - Medical 179

Electric Cell-Signaling Energy Waves (EcST and ESI) Medicaid - Medical 179

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

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

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

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

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

Extracorporeal Photopheresis Commercial - Medical 237

Extracorporeal Photopheresis Medicaid - Medical 237

Fecal Bacteriotherapy Commercial - Medical 181

Fecal Bacteriotherapy Medicaid - Medical 181

Fecal Incontinence Treatments Commercial - Medical 300

Fecal Incontinence Treatments Medicaid - Medical 300

Fetal Magnetic Cardiac Signal Commercial - Medical 297

Fetal Magnetic Cardiac Signal Medicaid -Medical 297

Fetal Magnetic Cardiac Signal Medicare - Medical 297

Gait analysis and surface electromyography Commercial - Medical 345.pdf

Gait Analysis and Surface Electromyography Medicaid - Medical 345.pdf

Gait Analysis and Surface Electromyography Medicare - Medical 345.pdf

Galectin 3 (LGALS3) Commercial - Medical 304

Galectin 3 (LGALS3) Medicaid - Medical 304

Galectin 3 (LGALS3) Medicare - Medical 304

Gastrointestinal Capsule Endoscopy Commercial - Medical 81

Gastrointestinal Capsule Endoscopy Medicaid - Medical 81

Genetic and Molecular Testing Medicaid Medical 34

Genetic and Molecular Testing Commercial Medical 34

Genicular Artery Embolization (GAE) Commercial - Medical 342

Genicular Artery Embolization (GAE) Medicaid - Medical 342

Home Health Aide Commercial - Medical 144

Home Health Aide Medicaid - Medical 144

Home Health Aide Medicare - Medical 144

Immunoglobulin Light Chains Commercial - Medical 333

Immunoglobulin Light Chains Medicaid - Medical 333

Immunoglobulin Light Chains Medicare - Medical 333

Implantable Hemodynamic Monitoring for Heart Failure Commercial - Medical 317

Implantable Hemodynamic Monitoring for Heart Failure Medicaid - Medical 317

Implantable Hemodynamic Monitoring for Heart Failure Medicare - Medical 317

Infrared Light Therapy and Low-Level Laser Therapy Commercial - Medical 109

Infrared Light Therapy and Low-Level Laser Therapy Medicaid - Medical 109

Ingestible Devices Commercial - Medical 344

Ingestible Devices Medicaid Medical 344.pdf

Ingestible Devices Medicare - Medical 344

Injectable Hormone Pellets Commercial - Medical 157

Intensive Cardiac Rehabilitation Programs Commercial - Medical 52

Intensive Cardiac Rehabilitation Programs Medicaid - Medical 52

Intra-arterial (IA) Chemotherapy Commercial - Medical 254

Intra-arterial (IA) Chemotherapy Medicaid - Medical 254

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

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

Long-Term Care Hospital (LTACH) Services Medicaid - Medical 335

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

Mitochondrial Antibody Testing Commercial - Medical 180.

Mitochondrial Antibody Testing Medicaid - Medical 180

Mitochondrial Antibody Testing Medicare - Medical 180

Mobile Cardiac Telemetry Commercial - Medical 112

Mobile Cardiac Telemetry Medicaid - Medical 112

Muscle Pain Detector Commercial - Medical 247

Muscle Pain Detector Medicaid - Medical 247

Near-infrared Spectroscopy Commercial - Medical 330

Near-infrared Spectroscopy Medicaid - Medical 330

Nonemergent Ambulance Services Commercial - Medical 105

Nonemergent Ambulance Services Medicaid - Medical 105

Non-Invasive Assessment of the Vasculature for Cardiovascular Risk Commercial - Medical 334

Non-Invasive Assessment of the Vasculature for Cardiovascular Risk Medicaid - Medical 334

Phase II Cardiac Rehabilitation Commercial - Medical 51

Phase II Cardiac Rehabilitation Medicaid - Medical 51

Photodynamic Therapy for Oncologic and Dermatologic Conditions Commercial - Medical 77

Photodynamic Therapy for Oncologic and Dermatologic Conditions Medicaid - Medical 77

Physical Therapy for Treating Obesity Commercial - Medical 252

Physical Therapy for Treating Obesity Medicaid - Medical 252

Physical Therapy for Treating Obesity Medicare - Medical 252

Platelet Rich-Plasma Commercial - Medical 246

Platelet Rich-Plasma Medicaid - Medical 246

Proton Beam Radiation Therapy (PBRT) Commercial - Medical 101

Proton Beam Radiation Therapy (PBRT) Medicaid - Medical 101.pdf

Sclerotherapy and Prolotherapy for Joints and Tendons Commercial - Medical 108

Sclerotherapy and Prolotherapy for Joints and Tendons Medicaid - Medical 108

Subacute Care Medicaid - Medical 346

Telemonitoring Services Medicaid - Medical 160

Transanal Double Balloon Enteroscopy Commercial - Medical 293

Transanal Double Balloon Enteroscopy Medicaid - Medical 293

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

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

Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Commercial - Medical 256

Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Medicaid - Medical 256

Transjugular Intrahepatic Portosystemic Shunt (TIPSS) Medicare - Medical 256

Transplant Rejection Testing Commercial - Medical 99

Transplant Rejection Testing Medicaid - Medical 99

Urinary Incontinence Treatments Commercial - Medical 130

Urinary Incontinence Treatments Medicaid - Medical 130

Vestibular Evoked Myogenic Potential (VEMP) Commercial - Medical 174

Vestibular Evoked Myogenic Potential (VEMP) Medicaid - Medical 174

Vestibular Rehabilitation Commercial - Medical 91

Vestibular Rehabilitation Medicaid - Medical 91

Vision Therapy for Convergence Insufficiency Commercial - Medical 324

Vision Therapy for Convergence Insufficiency Medicaid - Medical 324

Vision Therapy for Convergence Insufficiency Medicare Medical 324

Wearable Monitoring and Treatment Devices Commercial Medical 259

Wearable Monitoring and Treatment Devices Medicaid Medical 259

Wearable Monitoring Devices Commercial Medical 259

Wearable Monitoring Devices Medicaid Medical 259

Wound Treatment Commercial - Medical 343

Wound Treatment Medicaid - Medical 343