Policy Title
(Listed Alphabetically) | Policy Number | Effective Date |
---|
25-hydroxyvitamin D Testing in Children and Adolescents (PDF) | CP.MP.157
| 12/13/2023 |
Acupuncture (PDF) | CP.MP.92 | 8/5/2024 |
Air Ambulance (PDF) | CP.MP.175 | 8/16/2024 |
Allergy Testing and Therapy (PDF) | CP.MP.100 | 12/13/2023 |
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF) | CP.MP.108 | 11/1/2024 |
Ambulatory Surgery Center Optimization (PDF) | CP.MP.158 | 8/25/2023 |
Applied Behavior Analysis (PDF) | CP.BH.104 | 3/29/2024 |
Applied Behavioral Analysis Documentation Requirements (PDF) | CP.BH.105 | 3/12/2024 |
Articular Cartilage Defect Repairs (PDF) | CP.MP.26 | 5/10/2024 |
Assisted Reproductive Technology (PDF) | CP.MP.55 | 3/29/2024 |
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF) | CP.BH.124 | 5/25/2023 |
Bariatric Surgery (PDF) | CP.MP.37 | 6/5/2024 |
Behavioral Health Treatment Documentation Requirements (PDF) | CP.BH.500 | 8/16/2024 |
Biofeedback (PDF) | CP.MP.168 | 2/23/2024 |
Biofeedback for Behavioral Health Disorders (PDF) | CP.BH.300 | 11/1/2024 |
Bone-Anchored Hearing Aid (PDF) | CP.MP.93 | 8/5/2024 |
Bronchial Thermoplasty (PDF) | CP.MP.110 | 5/25/2023 |
Burn Surgery (PDF) | CP.MP.186 | 2/23/2024 |
Cardiac Biomarker Testing (PDF) | CP.MP.156 | 12/13/2023 |
Caudal or Interlaminar Epidural Steroid Injections (PDF) | CP.MP.164 | 8/5/2024 |
Clinical Practice & Preventive Health Guidelines (PDF) | CPG GRID | 9/18/2023 |
Clinical Trials (PDF) | CP.MP.94 | 8/5/2024 |
Cochlear Implant Replacements (PDF) | CP.MP.14 | 8/5/2024 |
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Cardiac Disorders (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Dermatologic Conditions (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Eye Disorders (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Gastroenterologic Disorders (Non-Cancerous) (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: General Approach to Genetic Testing (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Hearing Loss (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Hematologic Conditions (Non-Cancerous) (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF) | V2.2024 | 7/11/2024
|
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Kidney Disorders (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Lung Disorders (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Pharmacogenetics (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Preimplantation Genetic Testing (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Prenatal and Preconception Carrier Screening | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS or PUBS) and Pregnancy Loss (PDF) | V2.2024 | 7/11/2024 |
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF) | V2.2024 | 7/11/2024 |
Concert Genetics Oncology: Algorithmic Testing (PDF) | V2.2024 | 7/11/2024 |
Concert Genetics Oncology: Cancer Screening (PDF) | V2.2024 | 7/11/2024 |
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF) | V2.2024 | 7/11/2024 |
Concert Genetics Oncology: Cytogenetic Testing (PDF) | V2.2024 | 7/11/2024 |
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) | V2.2024 | 7/11/2024 |
Cosmetic and Reconstructive Procedures (PDF) | CP.MP.31 | 11/1/2024 |
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF) | CP.BH.201 | 6/5/2024 |
Diaphragmatic/Phrenic Nerve Stimulation (PDF) | CP.MP.203 | 10/4/2024 |
Digital EEG Spike Analysis (PDF) | CP.MP.105 | 3/29/2024 |
Disc Decompression Procedures (PDF) | CP.MP.114 | 8/16/2024 |
Discography (PDF) | CP.MP.115 | 8/16/2024 |
Donor Lymphocyte Infusion (PDF) | CP.MP.101 | 7/5/2024 |
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF) | CP.MP.107 | 8/16/2024 |
EEG in the Evaluation of Headache (PDF) | CP.MP.155 | 12/13/2023 |
Electric Tumor Treating Fields (Optune) (PDF) | CP.MP.145 | 2/23/2024 |
Endometrial Ablation (PDF) | CP.MP.106 | 5/25/2023 |
Evoked Potential Testing (PDF) | CP.MP.134 | 12/13/2023 |
Experimental Technologies (PDF) | CP.MP.36 | 6/5/2024 |
Facet Joint Interventions (PDF) | CP.MP.171 | 8/5/2024 |
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) | CP.MP.248 | 3/29/2024 |
Fecal Incontinence Treatments (PDF) | CP.MP.137 | 8/5/2024 |
Fertility Preservation (PDF) | CP.MP.130 | 3/29/2024 |
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) | CP.MP.129 | 8/5/2024 |
Functional MRI (PDF) | CP.MP.43 | 5/30/2024 |
Gastric Electrical Stimulation (PDF) | CP.MP.40 | 5/10/2024 |
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) | CP.MP.209 | 5/25/2023 |
Gender-Affirming Procedures (PDF) | CP.MP.95 | 10/4/2024 |
Heart-Lung Transplant (PDF) | CP.MP.132 | 5/10/2024 |
Helicobacter Pylori Serology Testing (PDF) | CP.MP.153 | 12/13/2023 |
Holter Monitors (PDF) | CP.MP.113 | 12/13/2023 |
Home Births (PDF) | CP.MP.136 | 3/29/2024 |
Home Ventilators (PDF) | CP.MP.184 | 8/16/2024 |
Homocysteine Testing (PDF) | CP.MP.121 | 5/25/2023 |
Hospice Services (PDF) | CP.MP.54 | 8/5/2024 |
Hyperhidrosis Treatments (PDF) | CP.MP.62 | 6/5/2024 |
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) | CP.MP.180 | 11/1/2024 |
Implantable Intrathecal or Epidural Pain Pump (PDF)
| CP.MP.173
| 3/29/2024 |
Implantable Loop Recorder | CP.MP.243 | 3/29/2024 |
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) | CP.MP.160 | 7/5/2024 |
Intensity-Modulated Radiotherapy (PDF) | CP.MP.69 | 7/5/2024 |
Intestinal and Multivisceral Transplant (PDF) | CP.MP.58 | 8/16/2024 |
Intradiscal Steroid Injections for Pain Management (PDF) | CP.MP.167 | 10/4/2024 |
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF) | CP.MP.61 | 11/1/2024 |
Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF) | CP.MP.250 | 10/4/2024 |
Laser Therapy for Skin Conditions (PDF) | CP.MP.123 | 5/25/2023 |
Liposuction for Lipedema (PDF) | CP.MP.244 | 8/16/2024 |
Long Term Care Placement (PDF) | CP.MP.71 | 5/10/2024 |
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) | CP.MP.139 | 5/25/2023 |
Lung Transplantation (PDF) | CP.MP.57 | 7/5/2024 |
Lysis of Epidural Lesions (PDF) | CP.MP.116 | 8/16/2024 |
Measurement of Serum 1,25-dihydroxyvitamin D (PDF) | CP.MP.152 | 12/13/2023 |
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) | CP.MP.144 | 2/23/2024 |
Multiple Sleep Latency Testing (PDF) | CP.MP.24 | 8/16/2024 |
Neonatal Abstinence Syndrome Guidelines (PDF) | CP.MP.86 | 3/29/2024 |
Neonatal Sepsis Management (PDF) | CP.MP.85 | 3/29/2024 |
Nerve Blocks and Neurolysis for Pain Management (PDF) | CP.MP.170 | 7/5/2024 |
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF) | CP.MP.48 | 8/5/2024 |
NICU Apnea Bradycardia Guidelines (PDF) | CP.MP.82 | 3/29/2024 |
NICU Discharge Guidelines (PDF) | CP.MP.81 | 3/29/2024 |
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF) | CP.MP.141 | 5/10/2024 |
Obstetrical Home Care Programs (PDF) | CP.MP.91 | 8/16/2024 |
Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF) | CP.MP.249 | 8/5/2024 |
Orthognathic Surgery (PDF) | CP.MP.202 | 11/1/2024 |
Osteogenic Stimulation (PDF) | CP.MP.194 | 10/4/2024 |
Outpatient Cardiac Rehabilitation (PDF) | CP.MP.176 | 7/5/2024 |
Outpatient Oxygen Use (PDF) | CP.MP.190 | 3/29/2024 |
Pancreas Transplantation (PDF) | CP.MP.102 | 5/10/2024 |
Panniculectomy (PDF) | CP.MP.109 | 11/1/2024 |
Pediatric Heart Transplant (PDF) | CP.MP.138 | 11/1/2024 |
Pediatric Kidney Transplant (PDF) | CP.MP.246 | 7/5/2024 |
Pediatric Liver Transplant (PDF) | CP.MP.120 | 8/16/2024 |
Pediatric Oral Function Therapy (PDF) | CP.MP.188 | 8/16/2024 |
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) | CP.MP.147 | 8/16/2024 |
Phototherapy for Neonatal Hyperbilirubinemia (PDF) | CP.MP.150 | 11/1/2024 |
Physical, Occupational, and Speech Therapy Services (PDF) | CP.MP.49 | 8/5/2024 |
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) | CP.MP.181 | 2/23/2024 |
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) | CP.MP.133 | 10/4/2024 |
Psychiatric Intesive Care (PIC) (PDF) | IA.CP.BH.500 | 8/30/2024 |
Proton and Neutron Beam Therapies (PDF) | CP.MP.70 | 2/23/2024 |
Pulmonary Function Testing (PDF) | CP.MP.242 | 5/25/2023 |
Reduction Mammoplasty and Gynecomastia Surgery (PDF) | CP.MP.51 | 8/5/2024 |
Repair of Nasal Valve Compromise (PDF) | CP.MP.210 | 8/16/2024 |
Sacroiliac Joint Fusion (PDF) | CP.MP.126 | 8/16/2024 |
Sacroiliac Joint Interventions for Pain Management (PDF) | CP.MP.166 | 10/4/2024 |
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF) | CP.MP.146 | 7/5/2024 |
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) | CP.MP.174 | 2/23/2024 |
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) | CP.MP.165 | 10/4/2024 |
Short Inpatient Hospital Stay (PDF) | CP.MP.182 | 7/5/2024 |
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF) | CP.MP.185 | 6/5/2024 |
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF) | CP.MP.117 | 8/16/2024 |
Stereotactic Body Radiation Therapy (PDF) | CP.MP.22 | 3/29/2024 |
Tandem Transplant (PDF) | CP.MP.162 | 5/10/2024 |
Testing for Select Genitourinary Conditions (PDF) | CP.MP.97 | 12/13/2023 |
Therapeutic Utilization of Inhaled Nitric Oxide (PDF) | CP.MP.87 | 10/4/2024 |
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) | CP.MP.154 | 12/13/2023 |
Total Artificial Heart (PDF) | CP.MP.127 | 8/5/2024 |
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) | CP.MP.163 | 5/10/2024 |
Transcatheter Closure of Patent Foramen Ovale (PDF) | CP.MP.151 | 2/23/2024 |
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF) | IA.CP.BH.200 | 10/04/2024 |
Transplant Service Documentation Requirements (PDF) | CP.MP.247 | 2/23/2024 |
Trigger Point Injections for Pain Management (PDF) | CP.MP.169 | 10/4/2024 |
Ultrasound in Pregnancy (PDF) | CP.MP.38 | 1/12/2024 |
Urinary Incontinence Devices and Treatments (PDF) | CP.MP.142 | 2/23/2024 |
Urodynamic Testing (PDF) | CP.MP.98 | 5/25/2023 |
Vagus Nerve Stimulation (PDF) | CP.MP.12 | 10/4/2024 |
Ventricular Assist Devices (PDF) | CP.MP.46 | 5/10/2024 |
Wireless Motility Capsule (PDF) | CP.MP.143 | 12/13/2023 |