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Name Type State Effective Inactive
Supervised Exercise Therapy for PAD Medical Policy NC Medicare 12/15/18
Supervised Exercise Therapy for PAD Medical Policy OH Medicare 12/15/18
Supervised Exercise Therapy for PAD Medical Policy PA Medicare 12/15/18
Biomarkers Overview Medical Policy PA Medicare 12/15/18
Hyperbaric Oxygen Therapy Medical Policy NC Medicare 12/15/18
Hyperbaric Oxygen Therapy Medical Policy OH Medicare 12/15/18
Hyperbaric Oxygen Therapy Medical Policy PA Medicare 12/15/18
MolDX: Molecular Diagnostic Tests Medical Policy NC Medicare 12/15/18
MolDX: Molecular Diagnostic Tests Medical Policy OH Medicare 12/15/18
Home Oxygen Therapy (HOT) Medical Policy PA Medicaid 12/15/18
Hyperbaric Oxygen Therapy (HBOT) Medical Policy PA Medicaid 12/15/18
Non-Oncologic Genetic Testing Panels Medical Policy PA Medicaid 12/15/18
Noninvasive Positive Pressure Intermittent Ventilation (NPPV) Medical Policy PA Medicaid 12/15/18
Oncologic Genetic Testing Panels Medical Policy PA Medicaid 12/15/18
Oncotype DX Medical Policy PA Medicaid 12/15/18
Wearable Cardioverter-Defibrillators in the Home Setting Medical Policy PA Medicaid 12/15/18
Automatic External Defibrillators Medical Policy NC Medicare 4/15/18
Testing for Genetic Disease Medical Policy NC Medicare 11/15/18
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy NC Medicare 11/15/18
Pharmacogenomic Testing for Warfarin Response Medical Policy NC Medicare 11/15/18
Automatic External Defibrillators Medical Policy KY Medicare 4/15/18
Testing for Genetic Disease Medical Policy KY Medicare 11/15/18
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy KY Medicare 11/15/18
Pharmacogenomic Testing for Warfarin Response Medical Policy KY Medicare 11/15/18
Automatic External Defibrillators Medical Policy OH Medicare 4/15/18
Testing for Genetic Disease Medical Policy OH Medicare 11/15/18
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy OH Medicare 11/15/18
Pharmacogenomic Testing for Warfarin Response Medical Policy OH Medicare 11/15/18
Automatic External Defibrillators Medical Policy PA Medicare 4/15/18
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy PA Medicare 11/15/18
Pharmacogenomic Testing for Warfarin Response Medical Policy PA Medicare 11/15/18
Testing of Genetic Disease Medical Policy PA Medicare 11/15/18
Soliris Medical Policy PA Medicare 11/15/18
Bariatric Surgery Medical Policy PA Medicaid 8/1/18
Fecal Microbiota Transplant Medical Policy PA Medicaid 11/15/18
Place of Service Medical Policy PA Medicaid 11/15/18
Genetic Testing for Colorectal Cancer Medical Policy PA Medicaid 11/15/18
Non-oncologic genetic testing panels Medical Policy PA Medicaid 11/15/18
Aloxi (Palonosetron Hydrochloride) Drug Policy PA Medicaid 10/1/18
Benlysta (belimumab) Drug Policy PA Medicaid 10/1/18
Cerezyme (Imiglucerase) Drug Policy PA Medicaid 10/1/18
Eylea (Aflibercept) Drug Policy PA Medicaid 10/1/18
Granulocyte Colony Stimulating Factors Drug Policy PA Medicaid 12/11/17
Lucentis (ranibizumab) Drug Policy PA Medicaid 10/1/18
Lumizyme® (alglucosidase alfa) Drug Policy PA Medicaid 10/1/18
Mozobil (plerixafor) Drug Policy PA Medicaid 10/1/18
Implantable Automatic Defibrillators Medical Policy KY Medicare 4/15/18
Implantable Automatic Defibrillators Medical Policy NC Medicare 4/15/18
Implantable Automatic Defibrillators Medical Policy OH Medicare 4/15/18
Implantable Automatic Defibrillators Medical Policy PA Medicare 4/15/18
Fetal Aneuploidy Medical Policy PA Medicare 10/1/18
Opdivo Drug
Policy
PA Medicare 10/1/18
Implantable Cardioverter-Defibrillator/ Subcutaneous Implantable Cardioverter-Defibrillator Medical Policy PA Medicaid 4/15/18
Molecular Markers for Fine Needle Aspirates of Thyroid Nodules Medical Policy PA Medicaid 10/1/18
BRAF Medical Policy PA Medicaid 10/1/18
Ambulance Air & Ground Medical Policy KY Medicare 9/15/18
Ambulance Air & Ground Medical Policy NC Medicare 9/15/18
Ambulance Air Medical Policy OH Medicare 9/15/18
Ambulance Air Medical Policy PA Medicare 9/15/18
Ambulance Ground Medical Policy KY Medicare 9/15/18
Ambulance Ground Medical Policy OH Medicare 9/15/18
Ambulance Ground Medical Policy PA Medicare 9/15/18
Carpal Tunnel Medical Policy PA Medicare 9/15/18
Carpal Tunnel Medical Policy OH Medicare 9/15/18
Carpal Tunnel Medical Policy NC Medicare 9/15/18
Carpal Tunnel Medical Policy KY Medicare 9/15/18
Fetal Aneuploidy Medical Policy PA Medicaid 9/15/18
Genetic Testing for Warfarin Medical Policy PA Medicaid 9/15/18
Macular Degeneration Medical Policy PA Medicaid 9/15/18
Molecular Testing in Lung Cancer Medical Policy PA Medicaid 9/15/18
Subcutaneous Implantable Cardioverter Defibrillator4 Medical Policy PA Medicare 9/15/18
Subcutaneous Implantable Cardioverter Defibrillator4 Medical Policy OH Medicare 9/15/18
Subcutaneous Implantable Cardioverter Defibrillator4 Medical Policy NC Medicare 9/15/18
Subcutaneous Implantable Cardioverter Defibrillator4 Medical Policy KY Medicare 9/15/18
Perjeta Medical Policy KY Medicare 9/15/18
Perjeta Medical Policy OH Medicare 9/15/18
Bariatric Surgery Medical Policy PA Medicaid 7/5/16
BCR-ABL1 Genetic Testing in Leukemia Medical Policy PA Medicaid 10/1/16
BRCA Medical Policy PA Medicaid 8/1/16
Breast Reconstruction Medical Policy PA Medicaid 7/19/17
Bronchial Thermoplasty Medical Policy PA Medicaid 7/19/17
Capsule Endoscopy Medical Policy PA Medicaid 3/1/17
Carpal Tunnel Medical Policy PA Medicaid 7/19/2017
Chromosomal Microarray Medical Policy PA Medicaid 10/1/16
Colorectal Cancer Screening Medical Policy PA Medicaid 8/1/17
Custom-Made Oral Appliances in the Treatment of Obstructive Sleep Apnea(OSA) Medical Policy PA Medicaid 05/01/17
Enteral Feeding In-line Cartridge Medical Policy PA Medicaid 07/19/17
Fetal Aneuploidy Medical Policy PA Medicaid 07/16/16
Gender Transition Services Medical Policy PA Medicaid 12/1/16
Carpal Tunnel Medical Policy Kentucky 9/15/17
Carpal Tunnel Medical Policy PA Medicare 9/15/17
Carpal Tunnel Medical Policy Ohio Medicare 9/15/17
Carpal Tunnel Medical Policy North Carolina Medicare 9/15/17
Testing for Genetic Disease Medical Policy PA Medicaid 06/17/16
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy PA Medicaid 10/1/16
Genetic Testing for Cystic Fibrosis Medical Policy PA Medicaid 04/14/16
Hyperbaric Oxygen Therapy (HBOT) Medical Policy PA Medicaid 7/5/2016
Implantable Cardioverter Defibrillator (ICD) Medical Policy PA Medicaid 07/19/17
Long-Term Use Continuous Glucose Monitoring of Interstitial Fluid Medical Policy PA Medicaid 05/01/17
Negative Pressure Wound Therapy in the Outpatient Setting Medical Policy PA Medicaid 12/1/16
Noninvasive Assessment of Liver Fibrosis in Chronic Hepatitis C Medical Policy PA Medicaid 06/02/16
Noninvasive Positive Pressure Intermittent Ventilation(NPPV) Medical Policy PA Medicaid 7/5/16
Oncotype DX Medical Policy PA Medicaid  
Panniculectomy Medical Policy PA Medicaid  
Passive Oscillatory Devices in the Outpatient Setting Medical Policy PA Medicaid  
Place of Service Medical Policy PA Medicaid  
Skin Replacement Therapy for Chronic Non-healing Wounds in the Outpatient Setting Medical Policy PA Medicaid  
Wearable Cardioverter-Defibrillator in Home Setting Medical Policy PA Medicaid  
Whole Exome and Whole Genome Genetic Testing Medical Policy PA Medicaid  
Bronchial Thermoplasty Medical Policy PA Medicare 8/1/17
Cataract Extraction Medical Policy PA Medicare 1/1/17
Fetal Aneuploidy Medical Policy PA Medicare 8/1/17

BronchialThermoplasty

Medical Policy OH Medicare 8/1/17
Cataract Extraction Medical Policy OH Medicare 1/1/17
Fetal Aneuploidy Medical Policy OH Medicare 8/1/17
Bronchial Thermoplasty Medical Policy KY Medicare 8/1/17
Cataract Extraction Medical Policy KY Medicare 1/1/17
Fetal Aneuploidy Medical Policy KY Medicare 8/1/17
Bronchial Thermoplasty Medical Policy NC Medicare 8/1/17
Cataract Extraction Medical Policy NC Medicare 1/1/17
Fetal Aneuploidy Medical Policy NC Medicare 8/1/17
Adcetris Drug
Policy
PA Medicaid 07/19/2017
Alimta Drug
Policy
PA Medicaid 12/1/2016
Avastin Drug
Policy
PA Medicaid 08/01/17
Faslodex Drug
Policy
PA Medicaid  
Herceptin Drug
Policy
PA Medicaid  
Interleukin-5 Inhibitors Drug
Policy
PA Medicaid  
Intravenous Immunoglobulin (IVIG) Drug
Policy
PA Medicaid  
Keytruda Drug
Policy
PA Medicaid  
Ocrevus Drug
Policy
PA Medicaid 8/1/17
Opdivo Drug
Policy
PA Medicaid  
Perjeta Drug
Policy
PA Medicaid  
Portrazza Drug
Policy
PA Medicaid  
Remicade® (Infliximab) Drug
Policy
PA Medicaid  
Soliris Drug
Policy
PA Medicaid 07/01/16
Spinraza Drug
Policy
PA Medicaid  
Tysabri Drug
Policy
PA Medicaid  
Vimizim Drug
Policy
PA Medicaid  
Xolair Drug
Policy
PA Medicaid  
Yervoy Drug
Policy
PA Medicaid  
Adcetris Drug
Policy
PA Medicare 07/19/2017
Alimta Drug
Policy
PA Medicare 08/01/2017
Botox Drug
Policy
PA Medicare 08/01/17
Exondys 51 Drug
Policy
PA Medicare 5/1/17
Faslodex Drug
Policy
PA Medicare 5/1/17
G-CSF Drug
Policy
PA Medicare 05/01/2017
Herceptin Drug
Policy
PA Medicare 8/1/2017
Interleukin-5 Inhibitors Drug
Policy
PA Medicare 05/01/17
Keytruda Drug
Policy
PA Medicare  
Kyprolis Drug
Policy
PA Medicare 8/1/17
Ocrevus Drug
Policy
PA Medicare 8/1/17
Perjeta Drug
Policy
PA Medicare  
Remicade Drug
Policy
PA Medicare  
Rituxan Drug
Policy
PA Medicare  
Tysabri Drug
Policy
PA Medicare 5/1/17
Vimizim Drug
Policy
PA Medicare  
Xolair Drug
Policy
PA Medicare 5/1/17
Portrazza Drug
Policy
PA Medicare  
Soliris Drug
Policy
PA Medicare 07/19/17
Spinraza Drug
Policy
PA Medicare 7/19/17
Velcade Drug
Policy
PA Medicare  
Adcetris Drug
Policy
OH Medicare 07/19/17
Exondys 51 Drug
Policy
OH Medicare 5/1/17
Faslodex Drug
Policy
OH Medicare 5/1/17
G-CSF Drug
Policy
OH Medicare 05/01/17
Interleukin-5 Inhibitors Drug
Policy
OH Medicare 5/1/17
Ocrevus Drug
Policy
OH Medicare 8/1/17
Perjeta Drug
Policy
OH Medicare 5/1/17
Spinraza Drug
Policy
OH Medicare  
Tysabri Drug
Policy
OH Medicare 5/1/17
Velcade Drug
Policy
OH Medicare  
Vimizim Drug
Policy
OH Medicare  
Xolair Drug
Policy
OH Medicare 5/1/17
Yervoy Drug
Policy
OH Medicare  
Adcetris Drug
Policy
KY Medicare 07/19/2017
Exondys 51 Drug
Policy
KY Medicare 5/1/17
Faslodex Drug
Policy
KY Medicare 5/1/17
G-CSF Drug
Policy
KY Medicare 05/01/2017
Interleukin-5 Inhibitors Drug
Policy
KY Medicare 5/1/17
Ocrevus Drug
Policy
KY Medicare 8/1/17
Perjeta Drug
Policy
KY Medicare 5/1/17
Spinraza Drug
Policy
KY Medicare 7/19/17
Tysabri Drug
Policy
KY Medicare 5/1/17
Velcade Drug
Policy
KY Medicare  
Vimizim Drug
Policy
KY Medicare  
Xolair Drug
Policy
KY Medicare 5/1/17
Yervoy Drug
Policy
KY Medicare  
Alimta Drug
Policy
NC Medicare 08/01/2017
Botox Drug
Policy
NC Medicare 08/01/17
Exondys 51 Drug
Policy
NC Medicare 5/1/17
Faslodex Drug
Policy
NC Medicare 5/1/17
G-CSF Drug
Policy
NC Medicare 05/01/2017
Interleukin-5 Inhibitors Drug
Policy
NC Medicare 5/1/17
Ocrevus Drug
Policy
NC Medicare 8/1/17
Perjeta Drug
Policy
NC Medicare 5/1/17
Soliris Drug
Policy
NC Medicare 07/19/17
Spinraza Drug
Policy
NC Medicare 7/19/17
Tysabri Drug
Policy
NC Medicare 5/1/17
Vimizim Drug
Policy
NC Medicare  
Xolair Drug
Policy
NC Medicare 5/1/17
G-CSF Drug
Policy
PA Medicaid 09/15/17
G-CSF Drug
Policy
PA Medicare 1/15/18
Interleukin-5 Inhibitors Drug
Policy
PA Medicare 1/15/18
Velcade Drug
Policy
PA Medicare 1/15/18
G-CSF Drug
Policy
OH Medicare 1/15/18
Interleukin-5 Inhibitors Drug
Policy
OH Medicare 1/15/18
Velcade Drug
Policy
OH Medicare 1/15/18
G-CSF Drug
Policy
KY Medicare 1/15/18
Interleukin-5 Inhibitors Drug
Policy
KY Medicare 1/15/18
Velcade Drug
Policy
KY Medicare 1/15/18
G-CSF​ Drug
Policy
NC Medicare 1/15/18
Interleukin-5 Inhibitors Drug
Policy
NC Medicare 1/15/18
Soliris Drug
Policy
NC Medicare 1/15/18
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy PA Medicaid 9/15/17
PA Place of Service Medical Policy PA Medicaid  
Botox Drug
Policy
PA Medicaid 08/01/17
Rituxan Drug
Policy
PA Medicaid  
Erbitux Drug
Policy
PA Medicaid  
Capsule Endoscopy Medical Policy PA Medicaid 5/1/17
Continuous Glucose Monitoring Medical Policy PA Medicaid 09/15/17
Kyprolis Drug
Policy
PA Medicaid 9/15/17
Spinraza Drug
Policy
PA Medicaid 7/19/17
Cardiac Rehab Medical Policy PA Medicaid  
Pulmonary Rehab Medical Policy PA Medicaid 9/15/17
Macular Degeneration Medical Policy PA Medicaid 10/1/17
Opdivo Drug
Policy
PA Medicare 5/1/17
Yervoy Drug
Policy
PA Medicare 5/1/17
Testing of Genetic Disease Medical Policy PA Medicare 12/1/17
Chromosomal Microarray Medical Policy PA Medicare 12/1/17
Testing of Genetic Disease Medical Policy OH Medicare 12/1/17
Chromosomal Microarray Medical Policy OH Medicare 12/1/17
Testing of Genetic Disease Medical Policy NC Medicare 12/1/17
Chromosomal Microarray Medical Policy NC Medicare 12/1/17
Testing of Genetic Disease Medical Policy KY Medicare 12/1/17
Chromosomal Microarray Medical Policy KY Medicare 12/1/17
Pulmonary Rehabilitation Medical Policy PA Medicare 12/1/17
Pulmonary Rehabilitation Medical Policy OH Medicare 12/1/17
Pulmonary Rehabilitation Medical Policy KY Medicare 12/1/17
Pulmonary Rehabilitation Medical Policy NC Medicare 12/1/17
Home Oxygen Therapy Medical Policy PA Medicare 2/15/18
Hyperbaric Oxygen Therapy Medical Policy PA Medicare 2/15/18
Hyperbaric Oxygen Therapy Medical Policy OH Medicare 2/15/18
Hyperbaric Oxygen Therapy Medical Policy KY Medicare 2/15/18
Hyperbaric Oxygen Therapy Medical Policy NC Medicare 2/15/18
Molecular Tumor Markers NSCLC Medical Policy PA Medicaid 12/1/17
BRAF Medical Policy PA Medicaid 12/1/17
Genetic Testing for Warfarin Medical Policy PA Medicaid 12/1/17
Molecular Markers for Fine Needle Aspirates of Thyroid Nodules Medical Policy PA Medicaid 12/1/17
Lupron Drug
Policy
PA Medicaid 12/1/17
Fecal Transplant Medical Policy PA Medicaid 2/15/18
Wearable Cardioverter Defibrillator Medical Policy PA Medicaid 2/15/18
Hyperbaric Oxygen Therapy Medical Policy PA Medicaid 2/15/18
Passive Oscillatory Devices Medical Policy PA Medicaid 2/15/18
Soliris Drug
Policy
PA Medicaid 12/1/17
Interleukin -5 Inhibitors Drug
Policy
PA Medicaid 12/1/17
Brineura Drug
Policy
PA Medicaid 1/15/18
G-CSF Drug
Policy
PA Medicaid 1/15/18
Soliris Drug
Policy
PA Medicare 1/15/18
Subcutaneous Implantable Cardioverter Defibrillator Medical Policy Kentucky 9/15/17
Subcutaneous Implantable Cardioverter Defibrillator Medical Policy PA Medicare 9/15/17
Subcutaneous Implantable Cardioverter Defibrillator Medical Policy Ohio 9/15/17
Subcutaneous Implantable Cardioverter Defibrillator Medical Policy North Carolina 9/15/17
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy Kentucky 10/1/17 10/1/18
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy PA Medicare 10/1/17 10/1/18
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy Ohio 10/1/17 10/1/18
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy North Carolina 10/1/17 10/1/18
Whole Exome and Whole Genome Sequencing Medical Policy Kentucky 10/1/17
Whole Exome and Whole Genome Sequencing Medical Policy PA Medicare 10/1/17
Whole Exome and Whole Genome Sequencing Medical Policy Ohio 10/1/17
Whole Exome and Whole Genome Sequencing Medical Policy North Carolina 10/1/17
Noninvasive Assessment of Liver Fibrosis Medical Policy Kentucky 9/15/17
Noninvasive Assessment of Liver Fibrosis Medical Policy PA Medicare 9/15/17
Noninvasive Assessment of Liver Fibrosis Medical Policy Ohio 9/15/17
Noninvasive Assessment of Liver Fibrosis Medical Policy North Carolina 9/15/17
Single/ Dual Cardiac Pacemakers Medical Policy PA Medicare 4/1/18
Leadless Pacemaker Medical Policy PA Medicare 4/1/18
Fecal Transplant Medical Policy PA Medicare 4/1/18
Single/ Dual Cardiac Pacemakers Medical Policy OH Medicare 4/1/18
Home Oxygen Therapy Medical Policy OH Medicare 4/1/18
Leadless Pacemaker Medical Policy OH Medicare 4/1/18
Fecal Transplant Medical Policy OH Medicare 4/1/18
Home Oxygen Therapy Medical Policy KY Medicare 4/1/18
Single/ Dual Cardiac Pacemakers Medical Policy KY Medicare 4/1/18
Leadless Pacemaker Medical Policy KY Medicare 4/1/18
Fecal Transplant Medical Policy KY Medicare 4/1/18
Home Oxygen Therapy Medical Policy NC Medicare 4/1/18
Single/ Dual Cardiac Pacemakers Medical Policy NC Medicare 4/1/18
Leadless Pacemaker Medical Policy NC Medicare 4/1/18
Fecal Transplant Medical Policy NC Medicare 4/1/18
Brineura Drug
Policy
PA Medicare 4/1/18
Brineura Drug
Policy
OH Medicare 4/1/18
Brineura Drug
Policy
KY Medicare 4/1/18
Brineura Drug
Policy
NC Medicare 4/1/18
Remicade Drug
Policy
PA Medicare 4/1/18
Negative Pressure Wound Therapy in the Outpatient Setting Medical Policy PA Medicaid 4/15/18
Electrical Bone Growth Stimulators for the Spine Medical Policy PA Medicaid 4/15/18
Colorectal Cancer Screening Medical Policy PA Medicaid 4/15/18
Implantable Cardioverter Defibrillator Medical Policy PA Medicaid 4/15/18
Capsule Endoscopy Medical Policy PA Medicaid 4/15/18
Panniculectomy Medical Policy PA Medicaid 4/15/18
Custom Made Oral Appliances Medical Policy PA Medicaid 4/15/18
Bariatric Surgery Medical Policy PA Medicaid 4/15/18
Cardiac Rhythm Device Evaluation Medical Policy PA Medicare 4/15/18
Cardiac Pacemaker Evaluation Services Medical Policy PA Medicare 4/15/18 10/1/18
Self-contained Cardiac Pacemakers Medical Policy PA Medicare 4/15/18
Automatic External Defibrillator Medical Policy PA Medicare 4/15/18
Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs) Medical Policy PA Medicare 4/15/18 10/1/18
Electrical Nerve Stimulator Medical Policy PA Medicare 4/15/18
Cochlear Implantation Medical Policy PA Medicare 4/15/18
Plethysmography Medical Policy PA Medicare 4/15/18
TMS Medical Policy PA Medicare 4/15/18
Implantable Cardioverter Defibrillator Medical Policy KY Medicare 4/15/18
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical Policy PA Medicare 4/15/18
Cardiac Pacemaker Evaluation Services Medical Policy OH Medicare 4/15/18
Self-contained Cardiac Pacemakers Medical Policy OH Medicare 4/15/18
Automatic External Defibrillator Medical Policy OH Medicare 4/15/18
Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs) Medical Policy OH Medicare 4/15/18
Electrical Nerve Stimulator Medical Policy OH Medicare 4/15/18
Cochlear Implantation Medical Policy OH Medicare 4/15/18
Plethysmography Medical Policy OH Medicare 4/15/18
TMS Medical Policy OH Medicare 4/15/18
Implantable Cardioverter Defibrillator Medical Policy OH Medicare 4/15/18
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical Policy OH Medicare 4/15/18
Transtelephonic Monitoring Medical Policy OH Medicare 4/15/18
Cardiac Pacemaker Evaluation Services Medical Policy KY Medicare 4/15/18
Self-contained Cardiac Pacemakers Medical Policy KY Medicare 4/15/18
Automatic External Defibrillator Medical Policy KY Medicare 4/15/18
Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs) Medical Policy KY Medicare 4/15/18
Electrical Nerve Stimulator Medical Policy KY Medicare 4/15/18
Cochlear Implantation Medical Policy KY Medicare 4/15/18
Plethysmography Medical Policy KY Medicare 4/15/18
TMS Medical Policy KY Medicare 4/15/18
Implantable Cardioverter Defibrillator Medical Policy KY Medicare 4/15/18
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical Policy KY Medicare 4/15/18
Transtelephonic Monitoring Medical Policy KY Medicare 4/15/18
Cardiac Pacemaker Evaluation Services Medical Policy NC Medicare 4/15/18
Self-contained Cardiac Pacemakers Medical Policy NC Medicare 4/15/18
Automatic External Defibrillator Medical Policy NC Medicare 4/15/18
Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs) Medical Policy NC Medicare 4/15/18
Electrical Nerve Stimulator Medical Policy NC Medicare 4/15/18
Cochlear Implantation Medical Policy NC Medicare 4/15/18
Plethysmography Medical Policy NC Medicare 4/15/18
TMS Medical Policy NC Medicare 4/15/18
Implantable Cardioverter Defibrillator Medical Policy NC Medicare 4/15/18
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical Policy NC Medicare 4/15/18
Transtelephonic Monitoring Medical Policy NC Medicare 4/15/18
Noninvasive Positive Pressure Ventilation Medical Policy PA Medicaid 4/15/18
Oncotype Genetic Testing Medical Policy PA Medicaid 4/15/18
Genetic Testing for Cystic Fibrosis Medical Policy PA Medicaid 4/15/18
Noninvasive Assessment of Liver Fibrosis Medical Policy PA Medicaid 4/15/18
BRCA 1 & 2 Genetic Testing Medical Policy PA Medicaid 4/15/18
Chromosomal Microarray Analysis Medical Policy PA Medicaid 4/15/18
BCR-AB1 Genetic Testing Medical Policy PA Medicaid 4/15/18
Skin Replacement Therapy Medical Policy PA Medicaid 4/15/18
Bronchial Thermoplasty Medical Policy PA Medicaid 4/15/18
Whole Exome and Whole Genome Medical Policy PA Medicaid 4/15/18
Testing for Genetic Disease Medical Policy PA Medicaid 4/15/18
Continuous Glucose Monitoring Medical Policy PA Medicaid 5/1/18
Cochlear Implants Medical Policy PA Medicaid 6/1/18
Noninvasive Assessment of Liver Fibrosis in Chronic Hepatitis C Medical Policy PA Medicaid 6/1/18
Velcade Drug
Policy
PA Medicaid 6/1/18
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA) Medical Policy PA Medicare 6/1/18
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA) Medical Policy OH Medicare 6/1/18
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA) Medical Policy KY Medicare 6/1/18
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA) Medical Policy NC Medicare 6/1/18
CPAP for Obstructive Sleep Apnea (OSA) Medical Policy PA Medicare 6/1/18
CPAP for Obstructive Sleep Apnea (OSA) Medical Policy OH Medicaid 6/1/18
CPAP for Obstructive Sleep Apnea (OSA) Medical Policy KY Medicaid 6/1/18
CPAP for Obstructive Sleep Apnea (OSA) Medical Policy NC Medicaid 6/1/18
Genetic Testing for Warfarin Therapy Medical Policy PA Medicare 6/1/18
Genetic Testing for Warfarin Therapy Medical Policy OH Medicare 6/1/18
Genetic Testing for Warfarin Therapy Medical Policy KY Medicare 6/1/18
Genetic Testing for Warfarin Therapy Medical Policy NC Medicare 6/1/18
Electrocardiographic Services Medical Policy PA Medicare 6/1/18
Electrocardiographic Services Medical Policy OH Medicare 6/1/18
Electrocardiographic Services Medical Policy NC Medicare 6/1/18
Electrocardiographic Services Medical Policy KY Medicare 6/1/18
Percutaneous Transluminal Angioplasty (PTA) Medical Policy PA Medicare 6/1/18
Percutaneous Transluminal Angioplasty (PTA) Medical Policy OH Medicare 6/1/18
Percutaneous Transluminal Angioplasty (PTA) Medical Policy NC Medicare 6/1/18
Percutaneous Transluminal Angioplasty (PTA) Medical Policy KY Medicare 6/1/18
Outpatient Sleep Studies Medical Policy PA Medicare 6/1/18
Cardiac Event Detection Monitoring Medical Policy PA Medicare 6/1/18
CV Nuclear Medicine Medical Policy PA Medicare 6/1/18
Spinal Cord Stimulation (Dorsal Column Stimulation) Medical Policy PA Medicare 6/1/18
Noninvasive Peripheral Venous Studies Medical Policy PA Medicare 6/1/18
Polysomnography and Other Sleep Studies Medical Policy OH Medicare 6/1/18
Cardiac Event Detection Medical Policy OH Medicare 6/1/18
CV Nuclear Medicine Medical Policy OH Medicare 6/1/18
Noninvasive Peripheral Venous Studies Medical Policy OH Medicare 6/1/18
Polysomnography and Other Sleep Studies Medical Policy KY Medicare 6/1/18
Cardiac Event Detection Medical Policy KY Medicare 6/1/18
CV Nuclear Medicine Medical Policy KY Medicare 6/1/18
Noninvasive Peripheral Venous Studies Medical Policy KY Medicare 6/1/18
Polysomnography and Other Sleep Studies Medical Policy NC Medicare 6/1/18
Cardiac Event Detection Medical Policy NC Medicare 6/1/18
Cardiac Radionuclide Imaging Medical Policy NC Medicare 6/1/18
Spinal Cord Stimulators for Chronic Pain Medical Policy NC Medicare 6/1/18
Cochlear Implantation Medical Policy PA Medicare 6/1/18
Cochlear Implantation Medical Policy OH Medicare 6/1/18
Cochlear Implantation Medical Policy KY Medicare 6/1/18
Cochlear Implantation Medical Policy NC Medicare 6/1/18
Home Oxygen Therapy Medical Policy PA Medicaid 12/01/17
Opdivo Drug
Policy
PA Medicare 7/15/18
Exondys 51 Drug
Policy
PA Medicare 7/15/18
Tysabri Drug
Policy
PA Medicare 7/15/18
Faslodex Drug
Policy
PA Medicare 7/15/18
Vimizim Drug
Policy
PA Medicare 7/15/18
Perjeta Drug
Policy
PA Medicare 7/15/18
Xolair Drug
Policy
PA Medicare 7/15/18
Yervoy Drug
Policy
PA Medicare 7/15/18
Adcetris Drug
Policy
PA Medicare 7/15/18
Portrazza Drug
Policy
PA Medicare 7/15/18
Spinraza Drug
Policy
PA Medicare 7/15/18
Ocrevus Drug
Policy
PA Medicare 7/15/18
Alimta Drug
Policy
PA Medicare 7/15/18
Herceptin Drug
Policy
PA Medicare 7/15/18
Keytruda Drug
Policy
PA Medicare 7/15/18
Kyprolis Drug
Policy
PA Medicare 7/15/18
Rituxan Drug
Policy
PA Medicare 7/15/18
Botox Drug
Policy
PA Medicare 7/15/18
Exondys 51 Drug
Policy
OH Medicare 7/15/18
Tysabri Drug
Policy
OH Medicare 7/15/18
Faslodex Drug
Policy
OH Medicare 7/15/18
Vimizim Drug
Policy
OH Medicare 7/15/18
Yervoy Drug
Policy
OH Medicare 7/15/18
Adcetris Drug
Policy
OH Medicare 7/15/18
Spinraza Drug
Policy
OH Medicare 7/15/18
Ocrevus Drug
Policy
OH Medicare 7/15/18
Exondys 51 Drug
Policy
KY Medicare 7/15/18
Tysabri Drug
Policy
KY Medicare 7/15/18
Faslodex Drug
Policy
KY Medicare 7/15/18
Vimizim Drug
Policy
KY Medicare 7/15/18
Yervoy Drug
Policy
KY Medicare 7/15/18
Adcetris Drug
Policy
KY Medicare 7/15/18
Spinraza Drug
Policy
KY Medicare 7/15/18
Ocrevus Drug
Policy
KY Medicare 7/15/18
Exondys 51 Drug
Policy
NC Medicare 7/15/18
Tysabri Drug
Policy
NC Medicare 7/15/18
Faslodex Drug
Policy
NC Medicare 7/15/18
Vimizim Drug
Policy
NC Medicare 7/15/18
Perjeta Drug
Policy
NC Medicare 7/15/18
Xolair Drug
Policy
NC Medicare 7/15/18
Spinraza Drug
Policy
NC Medicare 7/15/18
Alimta Drug
Policy
NC Medicare 7/15/18
Botox Drug
Policy
NC Medicare 7/15/18
Ocrevus Drug
Policy
NC Medicare 7/15/18
Ambulatory Blood Pressure Monitors Medical Policy PA Medicaid 7/15/18
Ambulatory Blood Pressure Monitors Medical Policy PA Medicare 7/15/18
Ambulatory Blood Pressure Monitors Medical Policy OH Medicare 7/15/18
Ambulatory Blood Pressure Monitors Medical Policy KY Medicare 7/15/18
Cataract Extraction Medical Policy PA Medicare 7/15/18
Bronchial Thermoplasty Medical Policy PA Medicare 7/15/18
Fetal Aneuploidy Medical Policy PA Medicare 7/15/18
Pulmonary Rehabilitation Medical Policy PA Medicare 7/15/18
Cataract Extraction Medical Policy OH Medicare 7/15/18
Cataract Extraction Medical Policy KY Medicare 7/15/18
Bronchial Thermoplasty Medical Policy OH Medicare 7/15/18
Bronchial Thermoplasty Medical Policy KY Medicare 7/15/18
Fetal Aneuploidy Medical Policy OH Medicare 7/15/18
Fetal Aneuploidy Medical Policy KY Medicare 7/15/18
Pulmonary Rehabilitation Medical Policy OH Medicare 7/15/18
Pulmonary Rehabilitation Medical Policy KY Medicare 7/15/18
Cataract Extraction Medical Policy NC Medicare 7/15/18
Bronchial Thermoplasty Medical Policy NC Medicare 7/15/18
Fetal Aneuploidy Medical Policy NC Medicare 7/15/18
Pulmonary Rehabilitation Medical Policy NC Medicare 7/15/18
Pulmonary Rehabilitation Medical Policy PA Medicaid 7/15/18
Xolair Drug
Policy
KY Medicare 7/15/18
Xolair Drug
Policy
OH Medicare 7/15/18
Fetal Aneuploidy Medical Policy PA Medicaid 08/15/17
Ambulatory Blood Pressure Monitors Medical Policy NC Medicare 7/15/18
Esophagogastroduodenoscopy (EGD) Medical Policy PA Medicaid 8/1/18
Bariatric Surgery Medical Policy PA Medicaid 8/1/18
Colorectal Cancer Screening Medical Policy PA Medicaid 8/1/18
Interleukin-5 Inhibitors Drug
Policy
PA Medicaid 8/1/18
Spinraza Drug
Policy
PA Medicaid 8/1/18 10/01/2018
Ocrevus Drug
Policy
PA Medicaid 8/1/18
Esophagogastroduodenoscopy (EGD) Medical Policy PA Medicare 8/1/18
Esophagogastroduodenoscopy (EGD) Medical Policy OH Medicare 8/1/18
Esophagogastroduodenoscopy (EGD) Medical Policy KY Medicare 8/1/18
Esophagogastroduodenoscopy (EGD) Medical Policy NC Medicare 8/1/18
Gender Transition Services Medical Policy PA Medicaid 9/1/18
Reconstructive Breast Surgery Medical Policy PA Medicaid 9/1/18
Carpal Tunnel Surgery Medical Policy PA Medicaid 9/1/18
Enteral Feeding In-line Cartridge Medical Policy PA Medicaid 9/1/18
Cardiac Rehabilitation Medical Policy PA Medicaid 9/1/18
Glucose Monitoring Medical Policy PA Medicare 9/1/18
Glucose Monitoring Medical Policy OH Medicare 9/1/18
Glucose Monitoring Medical Policy KY Medicare 9/1/18
Glucose Monitoring Medical Policy NC Medicare 9/1/18
Noninvasive Technique for the Evaluation of Liver Fibrosis Medical Policy PA Medicare 9/1/18
Chromosomal Microarray Medical Policy PA Medicare 9/1/18
Noninvasive Technique for the Evaluation of Liver Fibrosis Medical Policy OH Medicare 9/1/18
Chromosomal Microarray Medical Policy OH Medicare 9/1/18
Noninvasive Technique for the Evaluation of Liver Fibrosis Medical Policy KY Medicare 9/1/18
Chromosomal Microarray Medical Policy KY Medicare 9/1/18
Noninvasive Technique for the Evaluation of Liver Fibrosis Medical Policy NC Medicare 9/1/18