medical-policies | Sentara Health Plans

Sentara Health Plans has developed medical policies that serve as guidelines for coverage decisions and assist with administering plan benefits. The policies express Sentara Health Plans' determination of whether certain services are medically necessary, and they are based upon a review of currently available clinical information. Medical policies are not a substitute for clinical judgment. These policies are not an explanation of benefits. Providers are reminded to always verify member benefits and prior authorization requirements for the requested service. Members may contact customer services representatives for specific coverage information. These medical policies do not supersede any regulatory requirements.

Medical policies can be highly technical and complex and are provided here for informational purposes. These medical policies are intended for use by health care professionals. The medical policies do not constitute medical advice or medical care. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. Sentara Health Plans members should discuss the information in the medical policies with their treating health care professionals.

Medical technology is constantly evolving, and these medical policies are subject to change without notice, although Sentara Health Plans will notify providers as required in advance of changes that could have a negative impact on benefits. Additional medical policies may be developed from time to time and some may be withdrawn from use. Medical policies that have become obsolete will be archived as appropriate.

Medicaid and Medicare Codes

Provider Medical Policies

Accelerated Partial Breast Irradiation
PDF, 469 KBLast Updated: 06/29/2023
PDF, 469 KBLast Updated: 06/29/2023
Accidental Dental Services
PDF, 479 KBLast Updated: 06/29/2023
PDF, 479 KBLast Updated: 06/29/2023
Actigraphy
PDF, 440 KBLast Updated: 06/29/2023
PDF, 440 KBLast Updated: 06/29/2023
Agile Patency System
PDF, 439 KBLast Updated: 06/29/2023
PDF, 439 KBLast Updated: 06/29/2023
Allogeneic Hematopoietic Stem Cell Transplantation
PDF, 481 KBLast Updated: 06/29/2023
PDF, 481 KBLast Updated: 06/29/2023
Ambulance Transport Services
PDF, 470 KBLast Updated: 06/29/2023
PDF, 470 KBLast Updated: 06/29/2023
Ambulatory Devices
PDF, 467 KBLast Updated: 06/29/2023
PDF, 467 KBLast Updated: 06/29/2023
Anterior Cervical Discectomy
PDF, 2 MBLast Updated: 06/29/2023
PDF, 2 MBLast Updated: 06/29/2023
Anti-Phospholipid Antibody Testing
PDF, 465 KBLast Updated: 06/29/2023
PDF, 465 KBLast Updated: 06/29/2023
Apheresis
PDF, 475 KBLast Updated: 06/29/2023
PDF, 475 KBLast Updated: 06/29/2023
Apixaban Eliquis Drug Level
PDF, 440 KBLast Updated: 06/29/2023
PDF, 440 KBLast Updated: 06/29/2023
Artificial Disc Replacement and Treatment
PDF, 489 KBLast Updated: 06/29/2023
PDF, 489 KBLast Updated: 06/29/2023
Augmentative Communication and Speech Generating Systems
PDF, 484 KBLast Updated: 06/29/2023
PDF, 484 KBLast Updated: 06/29/2023
Autologous Hematopoietic Stem Cell Transplantation
PDF, 474 KBLast Updated: 06/29/2023
PDF, 474 KBLast Updated: 06/29/2023
Autologous Myoblast and Muscle Cell Injection
PDF, 444 KBLast Updated: 06/29/2023
PDF, 444 KBLast Updated: 06/29/2023
Autologous Serum Tears
PDF, 444 KBLast Updated: 06/29/2023
PDF, 444 KBLast Updated: 06/29/2023
Automated External Defibrillators
PDF, 465 KBLast Updated: 06/29/2023
PDF, 465 KBLast Updated: 06/29/2023
Automated Nerve Conduction Testing
PDF, 468 KBLast Updated: 06/29/2023
PDF, 468 KBLast Updated: 06/29/2023
Balloon Eustachian Tuboplasty
PDF, 440 KBLast Updated: 06/29/2023
PDF, 440 KBLast Updated: 06/29/2023
Bariatric Services
PDF, 491 KBLast Updated: 06/29/2023
PDF, 491 KBLast Updated: 06/29/2023
Benign Prostatic Hypertrophy Treatments as an Alternative to TURP
PDF, 476 KBLast Updated: 06/28/2023
PDF, 476 KBLast Updated: 06/28/2023
Blepharoplasty
PDF, 480 KBLast Updated: 06/28/2023
PDF, 480 KBLast Updated: 06/28/2023
Blepharoptosis Repair
PDF, 476 KBLast Updated: 06/28/2023
PDF, 476 KBLast Updated: 06/28/2023
Bone Scaffolding
PDF, 476 KBLast Updated: 06/28/2023
PDF, 476 KBLast Updated: 06/28/2023
Brachytherapy
PDF, 479 KBLast Updated: 06/28/2023
PDF, 479 KBLast Updated: 06/28/2023
Breast Procedures
PDF, 504 KBLast Updated: 06/28/2023
PDF, 504 KBLast Updated: 06/28/2023
Bronchial Thermoplasty for the Treatment of Asthma
PDF, 446 KBLast Updated: 06/28/2023
PDF, 446 KBLast Updated: 06/28/2023
Brow Lift
PDF, 473 KBLast Updated: 06/28/2023
PDF, 473 KBLast Updated: 06/28/2023
Bulking Agents for Vocal Cord Insufficiency
PDF, 478 KBLast Updated: 06/28/2023
PDF, 478 KBLast Updated: 06/28/2023
Capsular Plication of the Hip
PDF, 436 KBLast Updated: 06/28/2023
PDF, 436 KBLast Updated: 06/28/2023
Capsule Endoscopy
PDF, 471 KBLast Updated: 06/28/2023
PDF, 471 KBLast Updated: 06/28/2023
Cell Enumeration
PDF, 445 KBLast Updated: 06/28/2023
PDF, 445 KBLast Updated: 06/28/2023
Cervical Laminectomy
PDF, 1 MBLast Updated: 06/28/2023
PDF, 1 MBLast Updated: 06/28/2023
Chemotherapy Administration
PDF, 473 KBLast Updated: 06/28/2023
PDF, 473 KBLast Updated: 06/28/2023
Chromoendoscopy
PDF, 440 KBLast Updated: 06/28/2023
PDF, 440 KBLast Updated: 06/28/2023
Coccygectomy
PDF, 448 KBLast Updated: 06/28/2023
PDF, 448 KBLast Updated: 06/28/2023
Colonic Lavage Therapy
PDF, 444 KBLast Updated: 06/28/2023
PDF, 444 KBLast Updated: 06/28/2023
Compression Stockings and Garments
PDF, 475 KBLast Updated: 06/28/2023
PDF, 475 KBLast Updated: 06/28/2023
Computer-Aided Detection (CAD) Non Breast Indications
PDF, 444 KBLast Updated: 06/28/2023
PDF, 444 KBLast Updated: 06/28/2023
Cone-Beam Computed Tomography Systems (CBCT)
PDF, 467 KBLast Updated: 06/28/2023
PDF, 467 KBLast Updated: 06/28/2023
Continuous Glucose Monitoring Systems
PDF, 471 KBLast Updated: 06/29/2023
PDF, 471 KBLast Updated: 06/29/2023
Continuous Passive Motion
PDF, 467 KBLast Updated: 06/28/2023
PDF, 467 KBLast Updated: 06/28/2023
Continuous Subcutaneous Insulin Infusion
PDF, 477 KBLast Updated: 06/28/2023
PDF, 477 KBLast Updated: 06/28/2023
Contrast Enhanced Spectral Mammography
PDF, 437 KBLast Updated: 06/28/2023
PDF, 437 KBLast Updated: 06/28/2023
Core Decomp Avascular Necrosis of Knee Ankle Elbow Shoulder (Surgical)
PDF, 451 KBLast Updated: 06/28/2023
PDF, 451 KBLast Updated: 06/28/2023
Corneal Cross Linking
PDF, 446 KBLast Updated: 06/28/2023
PDF, 446 KBLast Updated: 06/28/2023
Corneal Hysteresis Measurement
PDF, 439 KBLast Updated: 06/28/2023
PDF, 439 KBLast Updated: 06/28/2023
Cosmetic and Reconstructive Surgery
PDF, 482 KBLast Updated: 06/28/2023
PDF, 482 KBLast Updated: 06/28/2023
Cranial Electrotherapy Stimulation
PDF, 446 KBLast Updated: 06/28/2023
PDF, 446 KBLast Updated: 06/28/2023
Cryoablation
PDF, 476 KBLast Updated: 06/28/2023
PDF, 476 KBLast Updated: 06/28/2023
Cytoreductive Surgery Tumor Debulking
PDF, 472 KBLast Updated: 06/28/2023
PDF, 472 KBLast Updated: 06/28/2023
Deep Brain Stimulation (surgical)
PDF, 471 KBLast Updated: 06/28/2023
PDF, 471 KBLast Updated: 06/28/2023
Dermal Fillers
PDF, 463 KBLast Updated: 06/28/2023
PDF, 463 KBLast Updated: 06/28/2023
Diabetic Shoes
PDF, 1 MBLast Updated: 06/28/2023
PDF, 1 MBLast Updated: 06/28/2023
Diapers and Underpads
PDF, 471 KBLast Updated: 06/28/2023
PDF, 471 KBLast Updated: 06/28/2023
Doula Services
PDF, 469 KBLast Updated: 06/28/2023
PDF, 469 KBLast Updated: 06/28/2023
Dry Hydrotherapy
PDF, 437 KBLast Updated: 06/28/2023
PDF, 437 KBLast Updated: 06/28/2023
Dry Needling
PDF, 157 KBLast Updated: 06/28/2023
PDF, 157 KBLast Updated: 06/28/2023
Early Inpatient Admission
PDF, 469 KBLast Updated: 06/28/2023
PDF, 469 KBLast Updated: 06/28/2023
Elective Termination of Pregnancy
PDF, 470 KBLast Updated: 06/28/2023
PDF, 470 KBLast Updated: 06/28/2023
Electric Cell Signaling Energy Waves ECST and ESI
PDF, 445 KBLast Updated: 06/29/2023
PDF, 445 KBLast Updated: 06/29/2023
Electric Electromagnetic Ultrasonic Bone Growth Stimulation
PDF, 477 KBLast Updated: 06/29/2023
PDF, 477 KBLast Updated: 06/29/2023
Electrical Bioimpedance
PDF, 471 KBLast Updated: 06/29/2023
PDF, 471 KBLast Updated: 06/29/2023
Electrical Stimulation
PDF, 490 KBLast Updated: 06/29/2023
PDF, 490 KBLast Updated: 06/29/2023
Electrical Stimulation and Electromagnetic Therapy for Wounds
PDF, 471 KBLast Updated: 06/29/2023
PDF, 471 KBLast Updated: 06/29/2023
Ellipsys Vascular Access System
PDF, 441 KBLast Updated: 06/29/2023
PDF, 441 KBLast Updated: 06/29/2023
Endometrial Ablation
PDF, 462 KBLast Updated: 06/29/2023
PDF, 462 KBLast Updated: 06/29/2023
EPAM Optima Health General Document .pdf
PDF, 25 KBLast Updated: 10/27/2023
PDF, 25 KBLast Updated: 10/27/2023
Epidermal Nerve Fiber Density Testing
PDF, 468 KBLast Updated: 06/29/2023
PDF, 468 KBLast Updated: 06/29/2023
Erector Spinae Plane Block
PDF, 442 KBLast Updated: 06/29/2023
PDF, 442 KBLast Updated: 06/29/2023
Exhaled Breath Condensate
PDF, 441 KBLast Updated: 06/29/2023
PDF, 441 KBLast Updated: 06/29/2023
Extracorporeal Photopheresis
PDF, 466 KBLast Updated: 06/29/2023
PDF, 466 KBLast Updated: 06/29/2023
Facet Joint Procedures
PDF, 2 MBLast Updated: 06/29/2023
PDF, 2 MBLast Updated: 06/29/2023
Facet Joint Procedures Surgical
PDF, 484 KBLast Updated: 06/29/2023
PDF, 484 KBLast Updated: 06/29/2023
Fecal Bacteriotherapy
PDF, 444 KBLast Updated: 06/29/2023
PDF, 444 KBLast Updated: 06/29/2023
Fecal Incontinence Treatments
PDF, 471 KBLast Updated: 06/29/2023
PDF, 471 KBLast Updated: 06/29/2023
Fetal Magnetic Cardiac Signal
PDF, 446 KBLast Updated: 06/29/2023
PDF, 446 KBLast Updated: 06/29/2023
Fetal Surgeries in Utero
PDF, 470 KBLast Updated: 06/29/2023
PDF, 470 KBLast Updated: 06/29/2023
Foot Orthotics
PDF, 1 MBLast Updated: 06/29/2023
PDF, 1 MBLast Updated: 06/29/2023
Foot Surgeries
PDF, 469 KBLast Updated: 06/29/2023
PDF, 469 KBLast Updated: 06/29/2023
Functional Electrical Stimulation Foot Drop System Hand Rehab
PDF, 466 KBLast Updated: 06/29/2023
PDF, 466 KBLast Updated: 06/29/2023
Galectin 3 (LGALS3)
PDF, 440 KBLast Updated: 06/29/2023
PDF, 440 KBLast Updated: 06/29/2023
Gastric Pacemakers Gastric Electrical Stimulators
PDF, 471 KBLast Updated: 06/29/2023
PDF, 471 KBLast Updated: 06/29/2023
Gastrointestinal Procedures
PDF, 477 KBLast Updated: 06/29/2023
PDF, 477 KBLast Updated: 06/29/2023
Genetic Testing and Biomarkers Medicare
PDF, 452 KBLast Updated: 01/08/2024
PDF, 452 KBLast Updated: 01/08/2024
Genetic Testing Cancer Prevention Diagnosis and Treatment
PDF, 740 KBLast Updated: 06/29/2023
PDF, 740 KBLast Updated: 06/29/2023
Genetic Testing Cardioneurovascular and Developmental Diagnosis
PDF, 407 KBLast Updated: 06/29/2023
PDF, 407 KBLast Updated: 06/29/2023
Genetic Testing Pharmacogenetic Testing
PDF, 190 KBLast Updated: 06/29/2023
PDF, 190 KBLast Updated: 06/29/2023
Genetic Testing Preconceptional-Prenatal-Preimplantation
PDF, 280 KBLast Updated: 06/29/2023
PDF, 280 KBLast Updated: 06/29/2023
Genetic Testing Pre-treatment or Post-intervention
PDF, 179 KBLast Updated: 06/29/2023
PDF, 179 KBLast Updated: 06/29/2023
Genicular Nerve Ablation
PDF, 440 KBLast Updated: 06/29/2023
PDF, 440 KBLast Updated: 06/29/2023
Headache Treatments
PDF, 470 KBLast Updated: 06/29/2023
PDF, 470 KBLast Updated: 06/29/2023
Heart Lung Transplantation
PDF, 473 KBLast Updated: 06/29/2023
PDF, 473 KBLast Updated: 06/29/2023
Heartsbreath Test
PDF, 438 KBLast Updated: 06/29/2023
PDF, 438 KBLast Updated: 06/29/2023
High Frequency Chest Wall Compression
PDF, 472 KBLast Updated: 06/29/2023
PDF, 472 KBLast Updated: 06/29/2023
High Intensity Focused Ultrasound
PDF, 467 KBLast Updated: 06/29/2023
PDF, 467 KBLast Updated: 06/29/2023
Hip Resurfacing Arthroplasty
PDF, 465 KBLast Updated: 06/29/2023
PDF, 465 KBLast Updated: 06/29/2023
Home Music Therapy
PDF, 439 KBLast Updated: 06/29/2023
PDF, 439 KBLast Updated: 06/29/2023
Home Spirometry
PDF, 446 KBLast Updated: 06/29/2023
PDF, 446 KBLast Updated: 06/29/2023
Home Traction Devices
PDF, 461 KBLast Updated: 06/29/2023
PDF, 461 KBLast Updated: 06/29/2023
Home Visual Field Monitoring Device
PDF, 447 KBLast Updated: 06/29/2023
PDF, 447 KBLast Updated: 06/29/2023
Hospital Beds and Accessories
PDF, 491 KBLast Updated: 06/29/2023
PDF, 491 KBLast Updated: 06/29/2023
Hyperhidrosis Treatment
PDF, 468 KBLast Updated: 06/29/2023
PDF, 468 KBLast Updated: 06/29/2023
Immunoglobulin Light Chains
PDF, 440 KBLast Updated: 06/29/2023
PDF, 440 KBLast Updated: 06/29/2023
Implantable Hemodynamic Monitoring for Heart Failure
PDF, 448 KBLast Updated: 06/29/2023
PDF, 448 KBLast Updated: 06/29/2023
Infertility Services Obstetrics
PDF, 467 KBLast Updated: 06/29/2023
PDF, 467 KBLast Updated: 06/29/2023
Infrared Light Therapy and Low-Level Laser Therapy
PDF, 453 KBLast Updated: 06/29/2023
PDF, 453 KBLast Updated: 06/29/2023
Injectable Hormone Pellets
PDF, 444 KBLast Updated: 06/29/2023
PDF, 444 KBLast Updated: 06/29/2023
Intensive Cardiac Rehabilitation Programs
PDF, 458 KBLast Updated: 06/29/2023
PDF, 458 KBLast Updated: 06/29/2023
Intra Oral Appliances and Splints for TMJ Syndrome
PDF, 471 KBLast Updated: 06/29/2023
PDF, 471 KBLast Updated: 06/29/2023
Intra-Arterial Chemotherapy
PDF, 465 KBLast Updated: 06/29/2023
PDF, 465 KBLast Updated: 06/29/2023
Intraoperative Neurophysiological Monitoring
PDF, 478 KBLast Updated: 06/29/2023
PDF, 478 KBLast Updated: 06/29/2023
Iontophoresis Treatment for Hyperhidrosis
PDF, 467 KBLast Updated: 06/29/2023
PDF, 467 KBLast Updated: 06/29/2023
Iron Quantification with Magnetic Resonance Imaging
PDF, 477 KBLast Updated: 06/29/2023
PDF, 477 KBLast Updated: 06/29/2023
Jaw Motion Rehabilitation Systems
PDF, 443 KBLast Updated: 06/29/2023
PDF, 443 KBLast Updated: 06/29/2023
Keratoconus Lenses and Interventions Piggyback Contact Lenses
PDF, 472 KBLast Updated: 06/29/2023
PDF, 472 KBLast Updated: 06/29/2023
Knee Arthroscopy
PDF, 218 KBLast Updated: 06/29/2023
PDF, 218 KBLast Updated: 06/29/2023
Laparoscopic Uterosacral Nerve Ablation Presacral Neurectomy
PDF, 443 KBLast Updated: 06/29/2023
PDF, 443 KBLast Updated: 06/29/2023
Laser Therapy
PDF, 473 KBLast Updated: 06/29/2023
PDF, 473 KBLast Updated: 06/29/2023
Leadless Cardiac Pacemaker
PDF, 446 KBLast Updated: 06/29/2023
PDF, 446 KBLast Updated: 06/29/2023
Left Atrial Appendage Occlusion
PDF, 464 KBLast Updated: 06/29/2023
PDF, 464 KBLast Updated: 06/29/2023
Lodging and Meal Reimbursement
PDF, 463 KBLast Updated: 06/29/2023
PDF, 463 KBLast Updated: 06/29/2023
Low Intensity Therapeutic Ultrasound Litus Devices
PDF, 440 KBLast Updated: 06/29/2023
PDF, 440 KBLast Updated: 06/29/2023
Lumbar Disc Arthroplasty
PDF, 1 MBLast Updated: 06/29/2023
PDF, 1 MBLast Updated: 06/29/2023
Lumbar Discectomy
PDF, 2 MBLast Updated: 06/29/2023
PDF, 2 MBLast Updated: 06/29/2023
Lumbar Fusion
PDF, 3 MBLast Updated: 06/29/2023
PDF, 3 MBLast Updated: 06/29/2023
Lumbar Laminectomy
PDF, 2 MBLast Updated: 06/29/2023
PDF, 2 MBLast Updated: 06/29/2023
Lymphedema Pump for Head and Neck
PDF, 443 KBLast Updated: 06/29/2023
PDF, 443 KBLast Updated: 06/29/2023
Magnetic Resonance Guided Focused Ultrasound (MRgFUS)
PDF, 473 KBLast Updated: 06/29/2023
PDF, 473 KBLast Updated: 06/29/2023
Mastectomy Garments
PDF, 442 KBLast Updated: 06/29/2023
PDF, 442 KBLast Updated: 06/29/2023
Medical Car Seats
PDF, 469 KBLast Updated: 06/29/2023
PDF, 469 KBLast Updated: 06/29/2023
Medical Dental Surgery
PDF, 470 KBLast Updated: 06/29/2023
PDF, 470 KBLast Updated: 06/29/2023
Minimally Invasive Lumbar Decompression
PDF, 608 KBLast Updated: 06/29/2023
PDF, 608 KBLast Updated: 06/29/2023
Miscellaneous Assistive Devices for Home Use
PDF, 196 KBLast Updated: 06/29/2023
PDF, 196 KBLast Updated: 06/29/2023
Miscellaneous Wound Management Therapies
PDF, 448 KBLast Updated: 06/29/2023
PDF, 448 KBLast Updated: 06/29/2023
Mitochondrial Antibody Testing
PDF, 439 KBLast Updated: 06/29/2023
PDF, 439 KBLast Updated: 06/29/2023
Mobile Cardiac Telemetry
PDF, 446 KBLast Updated: 06/29/2023
PDF, 446 KBLast Updated: 06/29/2023
Neuromuscular Electrical Stimulator
PDF, 237 KBLast Updated: 06/29/2023
PDF, 237 KBLast Updated: 06/29/2023
Percutaneous Antegrade Transseptal Transcatheter Mitral Valve Implantation
PDF, 695 KBLast Updated: 06/29/2023
PDF, 695 KBLast Updated: 06/29/2023
Platelet Rich Plasma Injections
PDF, 443 KBLast Updated: 06/29/2023
PDF, 443 KBLast Updated: 06/29/2023
Screening for Fetal Aneuploidy
PDF, 174 KBLast Updated: 06/29/2023
PDF, 174 KBLast Updated: 06/29/2023
Transvenous Implantable Cardioverter Defibrillator
PDF, 1 MBLast Updated: 06/29/2023
PDF, 1 MBLast Updated: 06/29/2023
Vestibular Function Testing
PDF, 179 KBLast Updated: 06/29/2023
PDF, 179 KBLast Updated: 06/29/2023