Policy Title (Listed Alphabetically) |
Policy Number |
Effective Date |
---|
25-hydroxyvitamin D Testing in Children and Adolescents (PDF) |
CP.MP.157
|
11/27/2022 |
Acupuncture (PDF) |
CP.MP.92 |
9/23/2022 |
Allergy Testing and Therapy (PDF) |
CP.MP.100 |
11/27/2022 |
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF) |
CP.MP.108 |
5/5/2023 |
Ambulatory Surgery Center Optimization (PDF) |
CP.MP.158 |
9/10/2022 |
Applied Behavioral Analysis (PDF) |
CP.BH.104 |
3/10/2023 |
Articular Cartilage Defect Repairs (PDF) |
CP.MP.26 |
5/5/2023 |
Assisted Reproductive Technology (PDF) |
CP.MP.55 |
4/7/2023 |
Attention Deficit Hyperactivity Disorder Assessment & Treatment (PDF) |
CP.BH.124 |
5/25/2023 |
Bariatric Surgery (PDF) |
CP.MP.37 |
9/10/2022 |
Behavioral Health Treatment Documentation Requirements (PDF) |
CP.BH.500 |
3/10/2023 |
Biofeedback (PDF) |
CP.MP.168 |
1/27/2023 |
Biofeedback for Behavioral Health Disorders (PDF) |
CP.BH.300 |
3/10/2023 |
Bone-Anchored Hearing Aid (PDF) |
CP.MP.93 |
9/10/2022 |
Bronchial Thermoplasty (PDF) |
CP.MP.110 |
5/25/2023 |
Burn Surgery (PDF) |
CP.MP.186 |
1/27/2023 |
Cardiac Biomarker Testing (PDF) |
CP.MP.156 |
11/27/2022 |
Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF) |
CP.MP.164 |
9/23/2022 |
Clinical Practice & Preventive Health Guidelines |
CPG GRID |
9/10/2022 |
Clinical Trials (PDF) |
CP.MP.94 |
9/10/2022 |
Cochlear Implant Replacements (PDF) |
CP.MP.14 |
9/23/2022 |
Cosmetic and Reconstructive Surgery (PDF) |
CP.MP.31 |
12/29/2022 |
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF) |
CP.BH.201 |
5/25/2023 |
Diaphragmatic/Phrenic Nerve Stimulation (PDF) |
CP.MP.203 |
3/10/2023 |
Digital Electroencephalography Spike Analysis (PDF) |
CP.MP.105 |
11/27/2022 |
Disc Decompression Procedures (PDF) |
CP.MP.114 |
8/5/2022 |
Discography (PDF) |
CP.MP.115 |
9/10/2022 |
Donor Lymphocyte Infusion (PDF) |
CP.MP.101 |
5/5/2023 |
Drugs of Abuse: Definitive Testing (PDF) |
CP.MP.50 |
5/25/2023 |
Durable Medical Equipment and Orthotics & Prosthetics Guidelines (PDF) |
CP.MP.107 |
3/10/2023 |
Electric Tumor Treating Fields (PDF) |
CP.MP.145 |
1/27/2023 |
Electroencephalography in the Evaluation of Headache (PDF) |
CP.MP.155 |
11/27/2022 |
Endometrial Ablation (PDF) |
CP.MP.106 |
5/25/2023 |
Evoked Potential Testing (PDF) |
CP.MP.134 |
11/27/2022 |
Experimental Technologies (PDF) |
CP.MP.36 |
5/5/2023 |
Facet Joint Interventions for Pain Management (PDF) |
CP.MP.171 |
9/23/2022 |
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF) |
CP.MP.248 |
5/25/2023 |
Fecal Incontinence Treatments (PDF) |
CP.MP.137 |
9/23/2022 |
Ferriscan R2-MRI (PDF) |
CP.MP.53 |
12/29/2022 |
Fertility Preservation (PDF) |
CP.MP.130 |
11/27/2022 |
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) |
CP.MP.129 |
9/23/2022 |
Functional MRI (PDF) |
CP.MP.43 |
5/5/2023 |
Gastric Electrical Stimulation (PDF) |
CP.MP.40 |
5/5/2023 |
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) |
CP.MP.209 |
5/25/2023 |
Gender-Affirming Procedures (PDF) |
CP.MP.95 |
4/7/2023 |
Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF) |
CP.MP.215 |
5/6/2022 |
Genetic Testing: Cardiac Disorders (PDF) |
CP.MP.216 |
5/6/2022 |
Genetic Testing: Dermatologic Conditions (PDF) |
CP.MP.217 |
5/6/2022 |
Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders (PDF) |
CP.MP.218 |
5/6/2022 |
Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF) |
CP.MP.219 |
5/6/2022 |
Genetic Testing: Eye Disorders (PDF) |
CP.MP.220 |
5/6/2022 |
Genetic Testing: Gastroenterologic Disorders (Non-Cancerous) (PDF) |
CP.MP.221 |
5/6/2022 |
Genetic Testing: General Approach to Genetic Testing (PDF) |
CP.MP.222 |
5/6/2022 |
Genetic Testing: Hearing Loss (PDF) |
CP.MP.223 |
5/6/2022 |
Genetic Testing: Hematologic Condition (Non-Cancerous) (PDF) |
CP.MP.224 |
5/6/2022 |
Genetic Testing: Hereditary Cancer Susceptibility (PDF) |
CP.MP.225 |
5/6/2022 |
Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF) |
CP.MP.226 |
5/6/2022 |
Genetic Testing: Kidney Disorders (PDF) |
CP.MP.227 |
5/6/2022 |
Genetic Testing: Lung Disorders (PDF) |
CP.MP.228 |
5/6/2022 |
Genetic Testing: Metabolic, Endocrine and Mitochondrial Disorders (PDF) |
CP.MP.229 |
5/6/2022 |
Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF) |
CP.MP.230 |
5/6/2022 |
Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF) |
CP.MP.231 |
5/6/2022 |
Genetic Testing: Pharmacogenetics (PDF) |
CP.MP.232 |
5/6/2022 |
Genetic Testing: Preimplantation (PDF) |
CP.MP.233 |
5/6/2022 |
Genetic Testing: Prenatal and Preconception Carrier Screening (PDF) |
CP.MP.234 |
5/6/2022 |
Genetic Testing: Prenatal Diagnosis (Via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF) |
CP.MP.235 |
5/6/2022 |
Genetic Testing: Skeletal Dyspasia and Rare Bone Disorders (PDF) |
CP.MP.236 |
5/6/2022 |
H. Pylori Serology Testing (PDF) |
CP.MP.153 |
11/27/2022 |
Heart-Lung Transplant (PDF) |
CP.MP.132 |
5/5/2023 |
Holter Monitors (PDF) |
CP.MP.113 |
11/27/2022 |
Home Births (PDF) |
CP.MP.136 |
4/7/2023 |
Home Ventilators (PDF) |
CP.MP.184 |
9/10/2022 |
Homocysteine Testing (PDF) |
CP.MP.121 |
5/25/2023 |
Hospice Services (PDF) |
CP.MP.54 |
3/10/2023 |
Hyperemesis Gravidarum Treatment (PDF) |
CP.MP.34 |
4/30/2022 |
Hyperhidrosis Treatments (PDF) |
CP.MP.62 |
4/7/2023 |
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) |
CP.MP.180 |
1/27/2023 |
Implantable Intrathecal or Epidural Pain Pump (PDF)
|
CP.MP.173
|
4/7/2023 |
Implantable Loop Recorder (PDF) |
CP.MP.243 |
8/15/2022 |
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) |
CP.MP.160 |
4/30/2022 |
Inhaled Nitric Oxide (PDF) |
CP.MP.87 |
7/1/2019 |
Intensity-Modulated Radiotherapy (PDF) |
CP.MP.69 |
3/10/2023 |
Intestinal and Multivisceral Transplant (PDF) |
CP.MP.58 |
8/5/2022 |
Intradiscal Steroid Injections for Pain Management (PDF) |
CP.MP.167 |
10/24/2022 |
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF) |
CP.MP.61 |
12/29/2022 |
Laser Therapy for Skin Conditions (PDF) |
CP.MP.123 |
5/25/2023 |
Liposuction for Lipedema (PDF) |
CP.MP.244 |
8/5/2022 |
Long Term Care Placement Criteria (PDF) |
CP.MP.71 |
4/30/2019 |
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) |
CP.MP.139 |
5/25/2023 |
Lung Transplantation (PDF) |
CP.MP.57 |
5/5/2023 |
Lysis of Epidural Lesions (PDF) |
CP.MP.116 |
8/5/2022 |
Measurement of Serum 1,25-Dihydroxyvitamin D (PDF) |
CP.MP.152 |
11/27/2022 |
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) |
CP.MP.144 |
1/27/2023 |
Multiple Sleep Latency Testing (PDF) |
CP.MP.24 |
4/30/2019 |
Neonatal Abstinence Syndrome Guidelines (PDF) |
CP.MP.86 |
5/5/2023 |
Neonatal Sepsis Management (PDF) |
CP.MP.85 |
5/5/2023 |
Neuromuscular & Peroneal Nerve Electrical Stimulation (NMES) (PDF) |
CP.MP.48 |
9/23/2022 |
Nerve Blocks and Neurolysis for Pain Management (PDF) |
CP.MP.170 |
10/24/2022 |
NICU Apnea Bradycardia Guidelines (PDF) |
CP.MP.82 |
9/10/2022 |
NICU Discharge Guidelines (PDF) |
CP.MP.81 |
5/5/2023 |
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF) |
CP.MP.141 |
5/5/2023 |
Obstetrical Home Care Programs (PDF) |
CP.MP.91 |
3/10/2023 |
Oncology Algorithmic Testing (PDF) |
CP.MP.237 |
5/6/2022 |
Oncology Cancer Screening (PDF) |
CP.MP.238 |
5/6/2022 |
Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF) |
CP.MP.239 |
5/6/2022 |
Oncology Cytogenetic Testing (PDF) |
CP.MP.240 |
5/6/2022 |
Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) |
CP.MP.241 |
5/6/2022 |
Optic Nerve Decompression Surgery (PDF) |
CP.MP.128 |
9/23/2022 |
Orthognathic Surgery (PDF) |
CP.MP.202 |
12/29/2022 |
Osteogenic Stimulation (PDF) |
CP.MP.194 |
11/27/2022 |
Outpatient Cardiac Rehabilitation (PDF) |
CP.MP.176 |
8/5/2022 |
Outpatient Oxygen Use (PDF) |
CP.MP.190 |
4/7/2023 |
Pancreas Transplant (PDF) |
CP.MP.102 |
5/5/2023 |
Panniculectomy (PDF) |
CP.MP.109 |
12/29/2022 |
Pediatric Heart Transplant (PDF) |
CP.MP.138 |
3/10/2023 |
Pediatric Kidney Transplant (PDF) |
CP.MP.246 |
11/27/2022 |
Pediatric Liver Transplant (PDF) |
CP.MP.120 |
5/5/2023 |
Pediatric Oral Function Therapy (PDF) |
CP.MP.188 |
8/5/2022 |
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) |
CP.MP.147 |
8/5/2022 |
Physical, Occupational & Speech Therapy Services (PDF) |
CP.MP.49 |
9/10/2022 |
Phototherapy for Neonatal Hyperbilirubinemia (PDF) |
CP.MP.150 |
12/29/2022 |
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) |
CP.MP.181 |
5/25/2023 |
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) |
CP.MP.133 |
10/24/2022 |
Proton and Neutron Beam Therapy (PDF) |
CP.MP.70 |
1/27/2023 |
Pulmonary Function Testing (PDF) |
CP.MP.242 |
5/25/2023 |
Radial Head Implant (PDF) |
CP.MP.148 |
8/5/2022 |
Radiofrequency Ablation of Uterine Fibroids (PDF) |
CP.MP.187 |
4/30/2022 |
Reduction Mammoplasty and Gynecomastia Surgery (PDF) |
CP.MP.51 |
9/23/2022 |
Repair of Nasal Valve Compromise (PDF) |
CP.MP.210 |
8/5/2022 |
Sacroiliac Joint Fusion (PDF) |
CP.MP.126 |
9/10/2022 |
Sacroiliac Joint Interventions for Pain Management (PDF) |
CP.MP.166 |
10/24/2022 |
Sclerotherapy for Varicose Veins (PDF) |
CP.MP.146 |
7/1/2019 |
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF) |
CP.MP.174 |
1/27/2023 |
Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF) |
CP.MP.165 |
10/24/2022 |
Short Inpatient Hospital Stay (PDF) |
CP.MP.182 |
1/27/2023 |
Skilled Nursing Facility Leveling (PDF) |
CP.MP.206 |
10/24/2022 |
Skin Substitutes for Chronic Wounds (PDF) |
CP.MP.185 |
12/29/2022 |
Spinal Cord, Peripheral Nerve and Percutaneous Electrical Nerve Stimulation (PDF) |
CP.MP.117 |
5/5/2023 |
Stereotactic Body Radiation Therapy (PDF) |
CP.MP.22 |
4/7/2023 |
Substance Use Disorders Treatment & Services (PDF) |
CP.BH.100 |
3/10/2023 |
Tandem Transplant (PDF) |
CP.MP.162 |
5/5/2023 |
Testing for Select Genitourinary Conditions (PDF) |
CP.MP.97 |
5/25/2023 |
Thyroid Hormones and Insulin Testing in Pediatrics (PDF) |
CP.MP.154 |
11/27/2022 |
Total Artificial Heart (PDF) |
CP.MP.127 |
12/29/2022 |
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) |
CP.MP.163 |
7/1/2019 |
Transcatheter Closure of Patent Foramen Ovale (PDF) |
CP.MP.151 |
1/27/2023 |
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF) |
ITC.BH.200 |
3/10/2023 |
Transplant Service Documentation Requirements (PDF) |
CP.MP.247 |
3/10/2023 |
Trigger Point Injections for Pain Management (PDF) |
CP.MP.169 |
10/24/2022 |
Ultrasound in Pregnancy (PDF) |
CP.MP.38 |
5/25/2023 |
Urinary Incontinence Devices and Treatments (PDF) |
CP.MP.142 |
1/27/2023 |
Urodynamic Testing (PDF) |
CP.MP.98 |
5/25/2023 |
Vagus Nerve Stimulation (PDF) |
CP.MP.12 |
10/24/2022 |
Ventricular Assist Devices (PDF) |
CP.MP.46 |
5/5/2023 |
Wheelchair Seating (PDF) |
CP.MP.99 |
5/25/2023 |
Wireless Motility Capsule (PDF) |
CP.MP.143 |
11/27/2022 |