Medicaid Medical Policy Archive Search

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Name	Type	State	Effective
Ambulatory Blood Pressure Monitors	Medical Policy	PA Medicaid	09/16/2019
Bariatric Surgery	Medical Policy	PA Medicaid	05/06/2019
BCR-ABL1 Genetic Testing in Leukemia	Medical Policy	PA Medicaid	03/16/2020
BRAF	Medical Policy	PA Medicaid	10/21/2019
BRCA1 & BRCA2 Genetic Testing	Medical Policy	PA Medicaid	06/17/2019
Bronchial Thermoplasty	Medical Policy	PA Medicaid	03/16/2020
Capsule Endoscopy	Medical Policy	PA Medicaid	03/16/2020
Carpal Tunnel Syndrome	Medical Policy	PA Medicaid	06/17/2019
Chromosomal Microarray Analysis	Medical Policy	PA Medicaid	03/16/2020
Cochlear Implants	Medical Policy	PA Medicaid	05/06/2019
Colorectal Cancer Screening	Medical Policy	PA Medicaid	04/13/2020
Continuous Glucose Monitoring	Medical Policy	PA Medicaid	06/17/2019
Custom-Made Oral Appliances in the Treatment of Obstructive Sleep Apnea (OSA)	Medical Policy	PA Medicaid	09/16/2019
Electrical Bone Growth Stimulators for the Spine	Medical Policy	PA Medicaid	05/06/2019
Enteral Feeding In-line Cartridge	Medical Policy	PA Medicaid	07/15/2019
Fetal Aneuploidy	Medical Policy	PA Medicaid	08/12/2019
Gender Transition Services	Medical Policy	PA Medicaid	05/06/2019
Genetic Testing for Cystic Fibrosis	Medical Policy	PA Medicaid	01/20/2020
Genetic Testing for Warfarin	Medical Policy	PA Medicaid	08/12/2019
Home Oxygen Therapy (HOT)	Medical Policy	PA Medicaid	10/21/2019
Hyperbaric Oxygen Therapy (HBOT)	Medical Policy	PA Medicaid	12/09/2019
Hypoglossal Nerve Stimulator	Medical Policy	PA Medicaid	03/16/2020
Implantable Cardioverter-Defibrillator/ Subcutaneous Implantable Cardioverter-Defibrillator	Medical Policy	PA Medicaid	08/12/2019
Molecular Markers for Fine Needle Aspirates of Thyroid Nodules	Medical Policy	PA Medicaid	10/21/2019
Molecular Tumor Markers for Non-Small Cell Lung Cancer (NSCLC)	Medical Policy	PA Medicaid	09/16/2019
Myoelectric Upper Extremity Orthoses	Medical Policy	PA Medicaid	02/17/2020
Negative Pressure Wound Therapy in the Outpatient Setting	Medical Policy	PA Medicaid	03/16/2020
Noninvasive Electrical Bone Growth Stimulators	Medical Policy	PA Medicaid	01/20/2020
Noninvasive Positive Pressure Intermittent Ventilation (NPPV)	Medical Policy	PA Medicaid	01/20/2020
Oncotype DX	Medical Policy	PA Medicaid	12/09/2019
Panniculectomy	Medical Policy	PA Medicaid	03/16/2020
Passive Oscillatory Devices in the Outpatient Setting	Medical Policy	PA Medicaid	01/20/2020
Place of Service	Medical Policy	PA Medicaid	01/20/2020
Pulmonary Rehabilitation	Medical Policy	PA Medicaid	04/13/2020
Supervised Exercise Therapy (SET)	Medical Policy	PA Medicaid	02/17/2020
Single Use ECG Monitoring (ZIO Patch)	Medical Policy	PA Medicaid	01/20/2020
Skin Replacement Therapy for Chronic Non-healing Wounds in the Outpatient Setting	Medical Policy	PA Medicaid	03/16/2020
Testing for Genetic Disease	Medical Policy	PA Medicaid	01/20/2020
Ultrasound Bone Growth Stimulator	Medical Policy	PA Medicaid	03/16/2020
Wearable Cardioverter-Defibrillators in the Home Setting	Medical Policy	PA Medicaid	11/18/2019
Whole Exome and Whole Genome Genetic Testing	Medical Policy	PA Medicaid	03/16/2020
Ambulance – Ground	Medical Policy	PA Medicaid	05/06/2019
Ambulance – Air	Medical Policy	PA Medicaid	04/13/2020
MRgFUS	Medical Policy	PA Medicaid	5/6/2019
Prostate Cancer Genetic Testing	Medical Policy	PA Medicaid	12/09/2019
Upper Gastrointestinal Endoscopy	Medical Policy	PA Medicaid	08/12/2019
Vitamin D Deficiency Testing	Medical Policy	PA Medicaid	06/17/2019
Treatment of Obstructive Sleep Apnea	Medical Policy	PA Medicaid	11/18/2019
Repetitive Transcranial Magnetic Stimulation	Medical Policy	PA Medicaid	11/18/2019
Gastric Electrical Stimulation (GES)	Medical Policy	PA Medicaid	12/09/2019
Bronchial Valves	Medical Policy	PA Medicaid	12/09/2019
Exhaled Nitric Oxide Measurement in the Management of Respiratory Disorders	Medical Policy	PA Medicaid	12/09/2019
Breast Scintimammography	Medical Policy	PA Medicaid	01/20/2020
DXA for Vertebral Fracture Assessment	Medical Policy	PA Medicaid	01/20/2020
Minimally Invasive Lumbar Decompression	Medical Policy	PA Medicaid	3/16/2020
Prostatic Urethral Lift	Medical Policy	PA Medicaid	3/16/2020
Multimarker Serum Testing for Ovarian Cancer	Medical Policy	PA Medicaid	3/16/2020
Speech Generating Devices	Medical Policy	PA Medicaid	3/16/2020
Reconstructive Breast Surgery	Medical Policy	PA Medicaid	06/17/2019
Cardiac Rehabilitation	Medical Policy	PA Medicaid	07/15/2019
Artificial Pancreas	Medical Policy	PA Medicaid	08/12/2019
Percutaneous Left Atrial Appendage Closure (LAAC)	Medical Policy	PA Medicaid	08/12/2019
Deep Brain Stimulation	Medical Policy	PA Medicaid	08/12/2019
Scanning Computerized Ophthalmic Imaging	Medical Policy	PA Medicaid	07/15/2019
Fecal Microbiota Transplant	Medical Policy	PA Medicaid	10/21/2019
Ambulance Services – Ground	Medical Policy	PA Medicaid	4/13/2020
Non-Oncologic Genetic Testing Panels	Medical Policy	PA Medicaid	11/18/2019
Oncologic Genetic Testing Panels	Medical Policy	PA Medicaid	11/18/2019
Cosmetic Procedures	Medical Policy	PA Medicaid	12/09/2019
Genetic Testing for Colorectal Cancer Susceptibility	Medical Policy	PA Medicaid	11/18/2019
Genetic Testing for Cystic Fibrosis	Medical Policy	PA Medicaid	05/18/2020
Electrical Stimulation for Oropharyngeal Dysphagia	Medical Policy	PA Medicaid	11/18/2019
Bariatric Surgery	Medical Policy	PA Medicaid	05/18/2020
Colorectal Cancer Screening	Medical Policy	PA Medicaid	04/13/2020
Electrical Bone Growth Stimulators for the Spine	Medical Policy	PA Medicaid	05/18/2020
MRgFUS	Medical Policy	PA Medicaid	5/18/2020
Single Use ECG Monitoring (ZIO Patch)	Medical Policy	PA Medicaid	12/21/2020
Gender Transition Services	Medical Policy	PA Medicaid	04/13/2020
Prescription Digital Therapeutics (e.g., reSET and reSET-O)	Medical Policy	PA Medicaid	12/21/2020
Enteral Feeding In-line Cartridge	Medical Policy	PA Medicaid	06/22/2020
Cardiac Rehabilitation	Medical Policy	PA Medicaid	06/22/2020
Deep Brain Stimulation	Medical Policy	PA Medicaid	07/27/2020
Cosmetic Procedures	Medical Policy	PA Medicaid	11/16/2020
Artificial Pancreas	Medical Policy	PA Medicaid	07/27/2020
BRCA1 & BRCA2 Genetic Testing	Medical Policy	PA Medicaid	06/22/2020
Breast Reconstructive Surgery	Medical Policy	PA Medicaid	06/22/2020
Carpal Tunnel Syndrome	Medical Policy	PA Medicaid	05/18/2020
Scanning Computerized Ophthalmic Imaging	Medical Policy	PA Medicaid	07/27/2020
Bronchial Thermoplasty	Medical Policy	PA Medicaid	04/19/2021
Colorectal Cancer Screening	Medical Policy	PA Medicaid	04/19/2021
Ambulance Services – Ground	Medical Policy	PA Medicaid	09/07/2020
Automated Ambulatory Blood Pressure Monitoring (ABPM)	Medical Policy	PA Medicaid	09/07/2020
Fecal Microbiota Transplant	Medical Policy	PA Medicaid	09/07/2020
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
Molecular Tumor Markers for Non-Small Cell Lung Cancer (NSCLC)	Medical Policy	PA Medicaid	10/19/2020
Repetitive Transcranial Magnetic Stimulation	Medical Policy	PA Medicaid	11/18/2019
Bronchial Thermoplasty	Medical Policy	PA Medicaid	08/16/2021
Fetal Testing Using Noninvasive Cell-Free Fetal DNA Aneuploidy	Medical Policy	PA Medicaid	08/17/2020
Upper Gastrointestinal Endoscopy (EGD-esophagogastroduodenoscopy)	Medical Policy	PA Medicaid	10/19/2020
Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP)	Medical Policy	PA Medicaid	10/19/2020
Vitamin D Deficiency Testing	Medical Policy	PA Medicaid	10/19/2020
BRAF Mutation Analysis	Medical Policy	PA Medicaid	10/19/2020
Cochlear Implants	Medical Policy	PA Medicaid	10/19/2020
Gastric Electrical Stimulation (GES)	Medical Policy	PA Medicaid	12/21/2020
Hyperbaric Oxygen Therapy (HBOT)	Medical Policy	PA Medicaid	11/16/2020
Molecular Markers for Fine Needle Aspirates of Thyroid Nodules	Medical Policy	PA Medicaid	10/19/2020
Treatment of Obstructive Sleep Apnea	Medical Policy	PA Medicaid	11/16/2020
Breast Scintimammography	Medical Policy	PA Medicaid	12/21/2020
Genetic Testing for Cystic Fibrosis	Medical Policy	PA Medicaid	12/21/2020
Myoelectric Upper Extremity Orthoses	Medical Policy	PA Medicaid	01/18/2021
DXA for Vertebral Fracture Assessment	Medical Policy	PA Medicaid	12/21/2020
Single-use Ambulatory Electrocardiographi c Monitors (e.g.. Zio Patch)	Medical Policy	PA Medicaid	04/19/2021
Supervised Exercise Therapy (SET)	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
Gene Expression Testing for Breast Cancer Treatment	Medical Policy	PA Medicaid	12/21/2020
Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis	Medical Policy	PA Medicaid	11/16/2020
Passive Oscillatory Devices in the Outpatient Setting	Medical Policy	PA Medicaid	01/18/2021
Prostate Cancer Genetic Testing	Medical Policy	PA Medicaid	12/21/2020

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.