Name
Type
State
Effective
Ambulatory Blood Pressure Monitors Medical PolicyPA Medicaid09/16/2019
Bariatric Surgery Medical PolicyPA Medicaid 05/06/2019
BCR-ABL1 Genetic Testing in Leukemia Medical PolicyPA Medicaid03/16/2020
BRAF Medical PolicyPA Medicaid10/21/2019
BRCA1 & BRCA2 Genetic Testing Medical PolicyPA Medicaid 06/17/2019
Bronchial Thermoplasty Medical PolicyPA Medicaid03/16/2020
Capsule Endoscopy Medical PolicyPA Medicaid03/16/2020
Carpal Tunnel Syndrome Medical PolicyPA Medicaid 06/17/2019
Chromosomal Microarray Analysis Medical PolicyPA Medicaid 03/16/2020
Cochlear Implants Medical PolicyPA Medicaid 05/06/2019
Colorectal Cancer Screening Medical PolicyPA Medicaid 04/13/2020
Continuous Glucose Monitoring Medical PolicyPA Medicaid 06/17/2019
Custom-Made Oral Appliances in the Treatment of Obstructive Sleep Apnea (OSA) Medical PolicyPA Medicaid09/16/2019
Electrical Bone Growth Stimulators for the Spine Medical PolicyPA Medicaid 05/06/2019
Enteral Feeding In-line Cartridge Medical PolicyPA Medicaid07/15/2019
Fetal Aneuploidy Medical PolicyPA Medicaid08/12/2019
Gender Transition Services Medical PolicyPA Medicaid 05/06/2019
Genetic Testing for Cystic Fibrosis Medical PolicyPA Medicaid01/20/2020
Genetic Testing for Warfarin Medical PolicyPA Medicaid08/12/2019
Home Oxygen Therapy (HOT) Medical PolicyPA Medicaid10/21/2019
Hyperbaric Oxygen Therapy (HBOT) Medical PolicyPA Medicaid12/09/2019
Hypoglossal Nerve Stimulator Medical PolicyPA Medicaid03/16/2020
Implantable Cardioverter-Defibrillator/ Subcutaneous Implantable Cardioverter-Defibrillator Medical PolicyPA Medicaid08/12/2019
Molecular Markers for Fine Needle Aspirates of Thyroid Nodules Medical PolicyPA Medicaid10/21/2019
Molecular Tumor Markers for Non-Small Cell Lung Cancer (NSCLC) Medical PolicyPA Medicaid09/16/2019
Myoelectric Upper Extremity Orthoses Medical PolicyPA Medicaid02/17/2020
Negative Pressure Wound Therapy in the Outpatient Setting Medical PolicyPA Medicaid03/16/2020
Noninvasive Electrical Bone Growth Stimulators Medical PolicyPA Medicaid01/20/2020
Noninvasive Positive Pressure Intermittent Ventilation (NPPV) Medical PolicyPA Medicaid01/20/2020
Oncotype DX Medical PolicyPA Medicaid12/09/2019
Panniculectomy Medical PolicyPA Medicaid03/16/2020
Passive Oscillatory Devices in the Outpatient Setting Medical PolicyPA Medicaid01/20/2020
Place of Service Medical PolicyPA Medicaid01/20/2020
Pulmonary Rehabilitation Medical PolicyPA Medicaid 04/13/2020
Supervised Exercise Therapy (SET) Medical PolicyPA Medicaid02/17/2020
Single Use ECG Monitoring (ZIO Patch) Medical PolicyPA Medicaid01/20/2020
Skin Replacement Therapy for Chronic Non-healing Wounds in the Outpatient Setting Medical PolicyPA Medicaid 03/16/2020
Testing for Genetic Disease Medical PolicyPA Medicaid01/20/2020
Ultrasound Bone Growth Stimulator Medical PolicyPA Medicaid03/16/2020
Wearable Cardioverter-Defibrillators in the Home Setting Medical PolicyPA Medicaid11/18/2019
Whole Exome and Whole Genome Genetic Testing Medical PolicyPA Medicaid03/16/2020
Ambulance – Ground Medical PolicyPA Medicaid05/06/2019
Ambulance – Air Medical PolicyPA Medicaid04/13/2020
MRgFUS Medical PolicyPA Medicaid5/6/2019
Prostate Cancer Genetic Testing Medical Policy PA Medicaid 12/09/2019
Upper Gastrointestinal Endoscopy Medical PolicyPA Medicaid08/12/2019
Vitamin D Deficiency Testing Medical PolicyPA Medicaid06/17/2019
Treatment of Obstructive Sleep Apnea Medical PolicyPA Medicaid11/18/2019
Repetitive Transcranial Magnetic Stimulation Medical PolicyPA Medicaid11/18/2019
Gastric Electrical Stimulation (GES) Medical Policy PA Medicaid 12/09/2019
Bronchial Valves Medical PolicyPA Medicaid12/09/2019
Exhaled Nitric Oxide Measurement in the Management of Respiratory Disorders Medical PolicyPA Medicaid12/09/2019
Breast Scintimammography Medical PolicyPA Medicaid01/20/2020
DXA for Vertebral Fracture Assessment Medical PolicyPA Medicaid01/20/2020
Minimally Invasive Lumbar Decompression Medical PolicyPA Medicaid3/16/2020
Prostatic Urethral Lift Medical PolicyPA Medicaid3/16/2020
Multimarker Serum Testing for Ovarian Cancer Medical PolicyPA Medicaid3/16/2020
Speech Generating Devices Medical PolicyPA Medicaid3/16/2020
Reconstructive Breast Surgery Medical PolicyPA Medicaid 06/17/2019
Cardiac Rehabilitation Medical PolicyPA Medicaid07/15/2019
Artificial Pancreas Medical PolicyPA Medicaid08/12/2019
Percutaneous Left Atrial Appendage Closure (LAAC) Medical PolicyPA Medicaid08/12/2019
Deep Brain Stimulation Medical PolicyPA Medicaid08/12/2019
Scanning Computerized Ophthalmic Imaging Medical PolicyPA Medicaid07/15/2019
Fecal Microbiota Transplant Medical PolicyPA Medicaid10/21/2019
Ambulance Services – Ground Medical PolicyPA Medicaid4/13/2020
Non-Oncologic Genetic Testing Panels Medical PolicyPA Medicaid11/18/2019
Oncologic Genetic Testing Panels Medical PolicyPA Medicaid11/18/2019
Cosmetic Procedures Medical Policy PA Medicaid 12/09/2019
Genetic Testing for Colorectal Cancer Susceptibility Medical PolicyPA Medicaid11/18/2019
Genetic Testing for Cystic Fibrosis Medical PolicyPA Medicaid05/18/2020
Electrical Stimulation for Oropharyngeal Dysphagia Medical PolicyPA Medicaid11/18/2019
Bariatric Surgery Medical PolicyPA Medicaid 05/18/2020
Colorectal Cancer Screening Medical PolicyPA Medicaid 04/13/2020
Electrical Bone Growth Stimulators for the Spine Medical PolicyPA Medicaid 05/18/2020
MRgFUS Medical PolicyPA Medicaid5/18/2020
Single Use ECG Monitoring (ZIO Patch) Medical PolicyPA Medicaid12/21/2020
Gender Transition Services Medical PolicyPA 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 PolicyPA Medicaid06/22/2020
Cardiac Rehabilitation Medical PolicyPA Medicaid06/22/2020
Deep Brain Stimulation Medical PolicyPA Medicaid07/27/2020
Cosmetic Procedures Medical Policy PA Medicaid 11/16/2020
Artificial Pancreas Medical PolicyPA Medicaid07/27/2020
BRCA1 & BRCA2 Genetic Testing Medical PolicyPA Medicaid 06/22/2020
Breast Reconstructive Surgery Medical PolicyPA Medicaid 06/22/2020
Carpal Tunnel Syndrome Medical PolicyPA Medicaid 05/18/2020
Scanning Computerized Ophthalmic Imaging Medical PolicyPA Medicaid07/27/2020
Bronchial Thermoplasty Medical PolicyPA Medicaid04/19/2021
Colorectal Cancer Screening Medical PolicyPA Medicaid 04/19/2021
Ambulance Services – Ground Medical PolicyPA Medicaid09/07/2020
Automated Ambulatory Blood Pressure Monitoring (ABPM) Medical PolicyPA Medicaid09/07/2020
Fecal Microbiota Transplant Medical PolicyPA Medicaid09/07/2020
Genetic Testing for Warfarin and Clopidogrel Therapy Medical PolicyPA Medicaid08/17/2020
Home Oxygen Therapy (HOT) Medical PolicyPA Medicaid09/07/2020
Molecular Tumor Markers for Non-Small Cell Lung Cancer (NSCLC) Medical PolicyPA Medicaid 10/19/2020
Repetitive Transcranial Magnetic Stimulation Medical PolicyPA Medicaid11/18/2019
Bronchial Thermoplasty Medical PolicyPA Medicaid08/16/2021
Fetal Testing Using Noninvasive Cell-Free Fetal DNA Aneuploidy Medical PolicyPA Medicaid08/17/2020
Upper Gastrointestinal Endoscopy (EGD-esophagogastroduodenoscopy) Medical PolicyPA Medicaid10/19/2020
Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP) Medical Policy PA Medicaid 10/19/2020
Vitamin D Deficiency Testing Medical PolicyPA Medicaid 10/19/2020
BRAF Mutation Analysis Medical PolicyPA Medicaid10/19/2020
Cochlear Implants Medical PolicyPA Medicaid 10/19/2020
Gastric Electrical Stimulation (GES) Medical Policy PA Medicaid 12/21/2020
Hyperbaric Oxygen Therapy (HBOT) Medical PolicyPA Medicaid11/16/2020
Molecular Markers for Fine Needle Aspirates of Thyroid Nodules Medical PolicyPA Medicaid10/19/2020
Treatment of Obstructive Sleep Apnea Medical PolicyPA Medicaid11/16/2020

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.

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