Medicaid Medical Policy Search

All drug policies are housed on the Medication Policy webpage. View all drug policies/criteria here.

Name	Type	State	Effective
Automated Ambulatory Blood Pressure Monitoring (ABPM)	Medical Policy	PA Medicaid	09/07/2020
Bariatric Surgery	Medical Policy	PA Medicaid	05/18/2020
BCR-ABL1 Testing in Chronic Muelogenous Leukemia and Acute Lymphoblastic Leukemia	Medical Policy	PA Medicaid	03/15/2021
BRAF Mutation Analysis	Medical Policy	PA Medicaid	10/19/2020
BRCA1 & BRCA2 Genetic Testing	Medical Policy	PA Medicaid	06/22/2020
Bronchial Thermoplasty	Medical Policy	PA Medicaid	03/16/2020
Capsule Endoscopy	Medical Policy	PA Medicaid	03/16/2020
Cardiac Rehabilitation	Medical Policy	PA Medicaid	06/22/2020
Carpal Tunnel Syndrome	Medical Policy	PA Medicaid	05/18/2020
Chromosomal Microarray Analysis	Medical Policy	PA Medicaid	03/16/2020
Cochlear Implants	Medical Policy	PA Medicaid	10/19/2020
Colorectal Cancer Screening	Medical Policy	PA Medicaid	04/13/2020
Custom-Made Oral Appliances in the Treatment of Obstructive Sleep Apnea (OSA)	Medical Policy	PA Medicaid	09/07/2020
Electrical Bone Growth Stimulators for the Spine	Medical Policy	PA Medicaid	05/18/2020
Enteral Feeding In-line Cartridge	Medical Policy	PA Medicaid	06/22/2020
Fecal Microbiota Transplant	Medical Policy	PA Medicaid	09/07/2020
Fetal Testing Using Noninvasive Cell-Free Fetal DNA Aneuploidy	Medical Policy	PA Medicaid	08/17/2020
Gender Transition Services	Medical Policy	PA Medicaid	04/13/2020
Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis	Medical Policy	PA Medicaid	11/16/2020
Genetic Testing for Cystic Fibrosis	Medical Policy	PA Medicaid	12/21/2020
Genetic Testing for Warfarin and Clopidogrel Therapy	Medical Policy	PA Medicaid	08/17/2020
Home Oxygen Therapy (HOT)	Medical Policy	PA Medicaid	09/07/2020
Hyperbaric Oxygen Therapy (HBOT)	Medical Policy	PA Medicaid	11/16/2020
Hypoglossal Nerve Stimulation Implantation i n the Treatment of Obstructive Sleep Apnea	Medical Policy	PA Medicaid	03/15/2021
Implantable Cardioverter-Defibrillator/ Subcutaneous Implantable Cardioverter-Defibrillator	Medical Policy	PA Medicaid	08/12/2019
Macular Degeneration	Medical Policy	PA Medicaid	08/12/2019
Molecular Markers for Fine Needle Aspirates of Thyroid Nodules	Medical Policy	PA Medicaid	10/19/2020
Molecular Tumor Markers for Non-Small Cell Lung Cancer (NSCLC)	Medical Policy	PA Medicaid	10/19/2020
Myoelectric Upper Extremity Orthoses	Medical Policy	PA Medicaid	01/18/2021
Negative Pressure Wound Therapy in the Outpatient Setting	Medical Policy	PA Medicaid	03/15/2021
Non-Oncologic Genetic Testing Panels	Medical Policy	PA Medicaid	11/16/2020
Noninvasive Electrical Bone Growth Stimulators (Osteogenesis Stimulators)	Medical Policy	PA Medicaid	01/18/2021
Noninvasive Positive Pressure Intermittent Ventilation in the Home Setting	Medical Policy	PA Medicaid	01/18/2021
Gene Expression Testing for Breast Cancer Treatment	Medical Policy	PA Medicaid	12/21/2020
Panniculectomy/Abdominoplasty/Lipectomy	Medical Policy	PA Medicaid	03/15/2021
Passive Oscillatory Devices in the Outpatient Setting	Medical Policy	PA Medicaid	01/18/2021
Place of Service	Medical Policy	PA Medicaid	10/19/2020
Pulmonary Rehabilitation	Medical Policy	PA Medicaid	04/13/2020
Breast Reconstructive Surgery	Medical Policy	PA Medicaid	06/22/2020
Supervised Exercise Therapy (SET)	Medical Policy	PA Medicaid	12/21/2020
Single Use ECG Monitoring (ZIO Patch)	Medical Policy	PA Medicaid	12/21/2020
Skin Replacement Therapy for Chronic Non-healing Wounds in the Outpatient Setting	Medical Policy	PA Medicaid	03/15/2021
Testing for Genetic Disease	Medical Policy	PA Medicaid	02/15/2021
Ultrasound Bone Growth Stimulator	Medical Policy	PA Medicaid	03/15/2021
Wearable Cardioverter-Defibrillators in the Home Setting	Medical Policy	PA Medicaid	01/18/2021
Whole Exome and Whole Genome Genetic Testing	Medical Policy	PA Medicaid	03/15/2021
Ambulance Services – Ground	Medical Policy	PA Medicaid	09/07/2020
MRgFUS	Medical Policy	PA Medicaid	5/18/2020
Prostate Cancer Genetic Testing	Medical Policy	PA Medicaid	12/21/2020
Upper Gastrointestinal Endoscopy (EGD-esophagogastroduodenoscopy)	Medical Policy	PA Medicaid	10/19/2020
Vitamin D Deficiency Testing	Medical Policy	PA Medicaid	10/19/2020
Scanning Computerized Ophthalmic Imaging	Medical Policy	PA Medicaid	07/27/2020
Artificial Pancreas	Medical Policy	PA Medicaid	07/27/2020
Percutaneous Left Atrial Appendage Closure (LAAC)	Medical Policy	PA Medicaid	07/27/2020
Deep Brain Stimulation	Medical Policy	PA Medicaid	07/27/2020
Treatment of Obstructive Sleep Apnea	Medical Policy	PA Medicaid	11/16/2020
Electrical Stimulation for Oropharyngeal Dysphagia	Medical Policy	PA Medicaid	01/18/2021
Repetitive Transcranial Magnetic Stimulation	Medical Policy	PA Medicaid	11/18/2019
Oncologic Genetic Testing Panels	Medical Policy	PA Medicaid	11/16/2020
Cosmetic Procedures	Medical Policy	PA Medicaid	11/16/2020
Gastric Electrical Stimulation (GES)	Medical Policy	PA Medicaid	12/21/2020
Bronchial Valves	Medical Policy	PA Medicaid	12/21/2020
Exhaled Nitric Oxide Measurement in the Management of Respiratory Disorders	Medical Policy	PA Medicaid	12/21/2020
Breast Scintimammography	Medical Policy	PA Medicaid	12/21/2020
DXA for Vertebral Fracture Assessment	Medical Policy	PA Medicaid	12/21/2020
Minimally Invasive Lumbar Decompression	Medical Policy	PA Medicaid	03/15/2021
Prostatic Urethral Lift	Medical Policy	PA Medicaid	03/15/2021
Multimarker Serum Testing for Ovarian Cancer	Medical Policy	PA Medicaid	03/15/2021
Speech Generating Devices	Medical Policy	PA Medicaid	3/16/2020
Labiaplasty	Medical Policy	PA Medicaid	4/13/2020
Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP)	Medical Policy	PA Medicaid	10/19/2020
Prescription Digital Therapeutics (e.g., reSET and reSET-O)	Medical Policy	PA Medicaid	12/21/2020