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 PolicyPA Medicaid09/07/2020
Bariatric Surgery Medical PolicyPA Medicaid 04/19/2021
BCR-ABL1 Testing in Chronic Muelogenous Leukemia and Acute Lymphoblastic Leukemia Medical PolicyPA Medicaid03/15/2021
BRAF Mutation Analysis Medical PolicyPA Medicaid10/19/2020
BRCA1 & BRCA2 Genetic Testing Medical PolicyPA Medicaid 06/22/2020
Bronchial Thermoplasty Medical PolicyPA Medicaid04/19/2021
Capsule Endoscopy Medical PolicyPA Medicaid04/19/2021
Cardiac Rehabilitation Medical PolicyPA Medicaid06/22/2020
Carpal Tunnel Syndrome Medical PolicyPA Medicaid 05/18/2020
Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) Medical PolicyPA Medicaid 04/19/2021
Cochlear Implants Medical PolicyPA Medicaid 10/19/2020
Colorectal Cancer Screening Medical PolicyPA Medicaid 04/19/2021
Custom-Made Oral Appliances in the Treatment of Obstructive Sleep Apnea (OSA) Medical PolicyPA Medicaid09/07/2020
Electrical Bone Growth Stimulators for the Spine(Osteogensis Stimulators) Medical PolicyPA Medicaid 04/19/2021
Enteral Feeding In-line Cartridge Medical PolicyPA Medicaid06/22/2020
Fecal Microbiota Transplant Medical PolicyPA Medicaid09/07/2020
Fetal Testing Using Noninvasive Cell-Free Fetal DNA Aneuploidy Medical PolicyPA Medicaid08/17/2020
Gender Affirmation Services Medical PolicyPA Medicaid 05/17/2021
Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis Medical PolicyPA Medicaid11/16/2020
Genetic Testing for Cystic Fibrosis Medical PolicyPA Medicaid12/21/2020
Genetic Testing for Warfarin and Clopidogrel Therapy Medical PolicyPA Medicaid08/17/2020
Home Oxygen Therapy (HOT) Medical PolicyPA Medicaid09/07/2020
Hyperbaric Oxygen Therapy (HBOT) Medical PolicyPA Medicaid11/16/2020
Hypoglossal Nerve Stimulation Implantation i n the Treatment of Obstructive Sleep Apnea Medical PolicyPA Medicaid03/15/2021
Implantable Cardioverter-Defibrillator/ Subcutaneous Implantable Cardioverter-Defibrillator Medical PolicyPA Medicaid08/12/2019
Macular Degeneration Medical PolicyPA Medicaid08/12/2019
Molecular Markers for Fine Needle Aspirates of Thyroid Nodules Medical PolicyPA Medicaid10/19/2020
Molecular Tumor Markers for Non-Small Cell Lung Cancer (NSCLC) Medical PolicyPA Medicaid 10/19/2020
Myoelectric Upper Extremity Orthoses Medical PolicyPA Medicaid01/18/2021
Negative Pressure Wound Therapy in the Outpatient Setting Medical PolicyPA Medicaid03/15/2021
Non-Oncologic Genetic Testing Panels Medical PolicyPA Medicaid11/16/2020
Noninvasive Electrical Bone Growth Stimulators (Osteogenesis Stimulators) Medical PolicyPA Medicaid01/18/2021
Noninvasive Positive Pressure Intermittent Ventilation in the Home Setting Medical PolicyPA Medicaid01/18/2021
Gene Expression Testing for Breast Cancer Treatment Medical PolicyPA Medicaid12/21/2020
Panniculectomy/Abdominoplasty/Lipectomy Medical PolicyPA Medicaid03/15/2021
Passive Oscillatory Devices in the Outpatient Setting Medical PolicyPA Medicaid01/18/2021
Place of Service Medical PolicyPA Medicaid10/19/2020
Pulmonary Rehabilitation (PR) Medical PolicyPA Medicaid 04/19/2021
Breast Reconstructive Surgery Medical PolicyPA Medicaid 06/22/2020
Supervised Exercise Therapy (SET) Medical PolicyPA Medicaid12/21/2020
Single-use Ambulatory Electrocardiographi c Monitors (e.g.. Zio Patch) Medical PolicyPA Medicaid04/19/2021
Skin Replacement Therapy for Chronic Non-healing Wounds in the Outpatient Setting Medical PolicyPA Medicaid 03/15/2021
Testing for Genetic Disease Medical PolicyPA Medicaid02/15/2021
Ultrasound Bone Growth Stimulator Medical PolicyPA Medicaid03/15/2021
Wearable Cardioverter-Defibrillators in the Home Setting Medical PolicyPA Medicaid01/18/2021
Whole Exome and Whole Genome Genetic Testing Medical PolicyPA Medicaid03/15/2021
Ambulance Services – Air Medical PolicyPA Medicaid04/19/2021
Ambulance Services – Ground Medical PolicyPA Medicaid09/07/2020
Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) Medical PolicyPA Medicaid04/19/2021
Prostate Cancer Genetic Testing Medical Policy PA Medicaid 12/21/2020
Upper Gastrointestinal Endoscopy (EGD-esophagogastroduodenoscopy) Medical PolicyPA Medicaid10/19/2020
Vitamin D Deficiency Testing Medical PolicyPA Medicaid 10/19/2020
Scanning Computerized Ophthalmic Imaging Medical PolicyPA Medicaid07/27/2020
Artificial Pancreas Medical PolicyPA Medicaid07/27/2020
Percutaneous Left Atrial Appendage Closure (LAAC) Medical PolicyPA Medicaid07/27/2020
Deep Brain Stimulation Medical PolicyPA Medicaid07/27/2020
Treatment of Obstructive Sleep Apnea Medical PolicyPA Medicaid11/16/2020
Electrical Stimulation for Oropharyngeal Dysphagia Medical PolicyPA Medicaid01/18/2021
Repetitive Transcranial Magnetic Stimulation Medical PolicyPA Medicaid11/18/2019
Oncologic Genetic Testing Panels Medical PolicyPA Medicaid11/16/2020
Cosmetic Procedures Medical Policy PA Medicaid 11/16/2020
Gastric Electrical Stimulation (GES) Medical Policy PA Medicaid 12/21/2020
Bronchial Valves Medical PolicyPA Medicaid12/21/2020
Exhaled Nitric Oxide Measurement in the Management of Respiratory Disorders Medical PolicyPA Medicaid12/21/2020
Breast Scintimammography Medical PolicyPA Medicaid12/21/2020
DXA for Vertebral Fracture Assessment Medical PolicyPA Medicaid12/21/2020
Minimally Invasive Lumbar Decompression Medical PolicyPA Medicaid03/15/2021
Prostatic Urethral Lift Medical PolicyPA Medicaid03/15/2021
Multimarker Serum Testing for Ovarian Cancer Medical PolicyPA Medicaid03/15/2021
Speech Generating Devices Medical PolicyPA Medicaid04/19/2021
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 05/17/2021
Gastrointestinal Pathogen Assays Medical Policy PA Medicaid 05/17/2021

Gateway Health Policy Disclaimer

  • The Policies neither constitutes nor substitutes for medical advice. Gateway Health’s Policies should not be construed as providing medical advice or treatment or guaranteeing the outcome or results of any medical services/treatments and/or procedures Providers are responsible for providing medical advice and treatment, are independent contractors, and are not employees or agents of Gateway Health. If members have a specific question about their medical condition, they should consult with their provider.
  • In the event of a conflict between the Policy and Member Handbook or Evidence of Coverage, the express terms of the Member Handbook or Evidence of Coverage will govern. The existence of a medical guideline is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the medical guideline.  The Policies are used in making decisions as to medical necessity only and they do not guarantee payment of services. Policies serve as one of the sets of guidelines for coverage decisions.
  • The information on this website may not reflect a recent policy change or all of the applicable medical guidelines.

Copyright 2021 Gateway Health Plan