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Medical Policy Search 



Name Type State Effective
Bariatric Surgery Medical Policy PA Medicaid  
BCR-ABL1 Genetic Testing in Leukemia Medical Policy PA Medicaid  
BRCA Medical Policy PA Medicaid  
Breast Reconstruction Medical Policy PA Medicaid  
Bronchial Thermoplasty Medical Policy PA Medicaid  
Capsule Endoscopy  Medical Policy PA Medicaid 3/1/17
Carpal Tunnel Medical Policy PA Medicaid  
Chromosomal Microarray Medical Policy PA Medicaid  
Colorectal Cancer Screening Medical Policy PA Medicaid  
Custom-Made Oral Appliances in the Treatment of Obstructive Sleep Apnea (OSA) Medical Policy PA Medicaid  
Enteral Feeding In-line Cartridge Medical Policy PA Medicaid  
Fetal Aneuploidy Medical Policy PA Medicaid  
Gender Transition Services Medical Policy PA Medicaid  
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
Genetic Disease Testing Medical Policy PA Medicaid  
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy PA Medicaid 10/1/16
Genetic Testing for Cystic Fibrosis Medical Policy PA Medicaid  
Hyperbaric Oxygen Therapy (HBOT) Medical Policy PA Medicaid  
Implantable Cardioverter Defibrillator (ICD) Medical Policy PA Medicaid  
Long-Term Use Continuous Glucose Monitoring of Interstitial Fluid Medical Policy PA Medicaid  
Negative Pressure Wound Therapy in the Outpatient Setting Medical Policy PA Medicaid  
Noninvasive Assessment of Liver Fibrosis in Chronic Hepatitis C Medical Policy PA Medicaid  
Noninvasive Positive Pressure Intermittent Ventilation(NPPV) Medical Policy PA Medicaid  
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  
Cataract Extraction Medical Policy PA Medicare  
Fetal Aneuploidy Medical Policy PA Medicare  

BronchialThermoplasty

Medical Policy OH Medicare  
Cataract Extraction Medical Policy OH Medicare  
Fetal Aneuploidy Medical Policy OH Medicare  
Bronchial Thermoplasty Medical Policy KY Medicare  
Cataract Extraction Medical Policy KY Medicare  
Fetal Aneuploidy Medical Policy KY Medicare  
Bronchial Thermoplasty Medical Policy NC Medicare  
Cataract Extraction Medical Policy NC Medicare  
Fetal Aneuploidy Medical Policy NC Medicare  
Adcetris Drug
Policy
PA Medicaid  
Alimta Drug
Policy
PA Medicaid  
Avastin Drug
Policy
PA Medicaid  
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  
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  
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  
Alimta Drug
Policy
PA Medicare  
Botox Drug
Policy
PA Medicare  
Exondys 51 Drug
Policy
PA Medicare  
Faslodex Drug
Policy
PA Medicare  
G-CSF Drug
Policy
PA Medicare  
Herceptin Drug
Policy
PA Medicare  
Interleukin-5 Inhibitors Drug
Policy
PA Medicare  
Keytruda Drug
Policy
PA Medicare  
Kyprolis Drug
Policy
PA Medicare  
Ocrevus Drug
Policy
PA Medicare  
Perjeta Drug
Policy
PA Medicare  
Remicade Drug
Policy
PA Medicare  
Rituxan Drug
Policy
PA Medicare  
Tysabri Drug
Policy
PA Medicare  
Vimizim Drug
Policy
PA Medicare  
Xolair Drug
Policy
PA Medicare  
Portrazza Drug
Policy
PA Medicare  
Soliris Drug
Policy
PA Medicare  
Spinraza Drug
Policy
PA Medicare  
Velcade Drug
Policy
PA Medicare  
Adcetris Drug
Policy
OH Medicare  
Exondys 51 Drug
Policy
OH Medicare  
Faslodex Drug
Policy
OH Medicare  
G-CSF Drug
Policy
OH Medicare  
Interleukin-5 Inhibitors Drug
Policy
OH Medicare  
Ocrevus Drug
Policy
OH Medicare  
Perjeta Drug
Policy
OH Medicare  
Spinraza Drug
Policy
OH Medicare  
Tysabri Drug
Policy
OH Medicare  
Velcade Drug
Policy
OH Medicare  
Vimizim Drug
Policy
OH Medicare  
Xolair Drug
Policy
OH Medicare  
Yervoy Drug
Policy
OH Medicare  
Adcetris Drug
Policy
KY Medicare  
Exondys 51 Drug
Policy
KY Medicare  
Faslodex Drug
Policy
KY Medicare  
G-CSF Drug
Policy
KY Medicare  
Interleukin-5 Inhibitors Drug
Policy
KY Medicare  
Ocrevus Drug
Policy
KY Medicare  
Perjeta Drug
Policy
KY Medicare  
Spinraza Drug
Policy
KY Medicare  
Tysabri Drug
Policy
KY Medicare  
Velcade Drug
Policy
KY Medicare  
Vimizim Drug
Policy
KY Medicare  
Xolair Drug
Policy
KY Medicare  
Yervoy Drug
Policy
KY Medicare  
Alimta Drug
Policy
NC Medicare  
Botox Drug
Policy
NC Medicare  
Exondys 51 Drug
Policy
NC Medicare  
Faslodex Drug
Policy
NC Medicare  
G-CSF Drug
Policy
NC Medicare  
Interleukin-5 Inhibitors Drug
Policy
NC Medicare  
Ocrevus Drug
Policy
NC Medicare  
Perjeta Drug
Policy
NC Medicare  
Soliris Drug
Policy
NC Medicare  
Spinraza Drug
Policy
NC Medicare  
Tysabri Drug
Policy
NC Medicare  
Vimizim Drug
Policy
NC Medicare  
Xolair Drug
Policy
NC Medicare  
G-CSF Drug
Policy
PA Medicaid  
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 9/15/2017
PA Place of Service Medical Policy PA Medicaid  
Botox Drug
Policy
PA Medicaid  
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  
Kyprolis Drug
Policy
PA Medicaid  
Spinraza Drug
Policy
PA Medicaid  
Cardiac Rehab Medical Policy PA Medicaid  
Pulmonary Rehab Medical Policy PA Medicaid  
Macular Degeneration Medical Policy PA Medicaid  
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
Home Oxygen Therapy 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
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy PA Medicare 10/1/17
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy Ohio 10/1/17
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy North Carolina 10/1/17
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
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
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