Medicare Medical Policy Archive Search

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Name	Type	State	Effective
Automatic External Defibrillator	Medical Policy	KY Medicare	04/15/2018
Botox	Drug Policy	NC Medicare	08/01/17
Botox	Drug Policy	PA Medicare	08/01/17
Bronchial Thermoplasty	Medical Policy	KY Medicare	08/01/17
Bronchial Thermoplasty	Medical Policy	NC Medicare	08/01/17
Bronchial Thermoplasty	Medical Policy	OH Medicare	08/01/17
Bronchial Thermoplasty	Medical Policy	PA Medicare	08/01/17
Cardiac Pacemaker Evaluation Services	Medical Policy	PA Medicare	04/15/18
Carpal Tunnel	Medical Policy	KY Medicare	09/15/17
Carpal Tunnel	Medical Policy	NC Medicare	09/15/17
Carpal Tunnel	Medical Policy	OH Medicare	09/15/17
Carpal Tunnel	Medical Policy	PA Medicare	09/15/17
Cataract Extraction	Medical Policy	KY Medicare	01/01/17
Cataract Extraction	Medical Policy	NC Medicare	01/01/17
Cataract Extraction	Medical Policy	OH Medicare	01/01/17
Cataract Extraction	Medical Policy	PA Medicare	01/01/17
Chromosomal Microarray	Medical Policy	KY Medicare	12/01/17
Chromosomal Microarray	Medical Policy	OH Medicare	12/01/17
Chromosomal Microarray	Medical Policy	PA Medicare	12/01/17
Cochlear Implantation	Medical Policy	KY Medicare	04/15/18
Exondys 51	Drug Policy	KY Medicare	05/01/17
Exondys 51	Drug Policy	NC Medicare	05/01/17
Exondys 51	Drug Policy	PA Medicare	05/01/17
Exondys 51	Drug Policy	OH Medicare	05/01/17
Faslodex	Drug Policy	KY Medicare	05/01/17
Faslodex	Drug Policy	NC Medicare	05/01/17
Faslodex	Drug Policy	OH Medicare	05/01/17
Faslodex	Drug Policy	PA Medicare	05/01/17
G-CSF	Drug Policy	KY Medicare	05/01/2017
G-CSF	Drug Policy	NC Medicare	05/01/2017
G-CSF	Drug Policy	OH Medicare	05/01/17
G-CSF	Drug Policy	PA Medicare	05/01/2017
Herceptin	Drug Policy	PA Medicare	08/01/2017
Hyperbaric Oxygen Therapy	Medical Policy	NC Medicare	02/15/18
Hyperbaric Oxygen Therapy	Medical Policy	OH Medicare	02/15/18
Hyperbaric Oxygen Therapy	Medical Policy	PA Medicare	02/15/18
Interleukin-5 Inhibitors	Drug Policy	KY Medicare	05/01/17
Interleukin-5 Inhibitors	Drug Policy	NC Medicare	05/01/17
Interleukin-5 Inhibitors	Drug Policy	OH Medicare	05/01/17
Interleukin-5 Inhibitors	Drug Policy	PA Medicare	05/01/17
Keytruda	Drug Policy	PA Medicare	08/01/17
Kyprolis	Drug Policy	PA Medicare	08/01/17
Ocrevus	Drug Policy	KY Medicare	08/01/17
Ocrevus	Drug Policy	NC Medicare	08/01/17
Ocrevus	Drug Policy	OH Medicare	08/01/17
Ocrevus	Drug Policy	PA Medicare	08/01/17
Opdivo	Drug Policy	PA Medicare	07/15/18
Opdivo	Drug Policy	PA Medicare	05/01/17
Outpatient Sleep Studies	Medical Policy	PA Medicare	06/01/2018
Perjeta	Drug Policy	PA Medicare	08/01/17
Perjeta	Drug Policy	NC Medicare	05/01/17
Portrazza	Drug Policy	PA Medicare	07/19/17
Pulmonary Rehabilitation	Medical Policy	KY Medicare	12/01/17
Pulmonary Rehabilitation	Medical Policy	NC Medicare	12/01/17
Pulmonary Rehabilitation	Medical Policy	OH Medicare	12/01/17
Pulmonary Rehabilitation	Medical Policy	PA Medicare	12/01/17
Remicade	Drug Policy	PA Medicare	08/01/17
Rituxan	Drug Policy	PA Medicare	08/01/17
Soliris	Medical Policy	PA Medicare	11/15/18
Soliris	Drug Policy	PA Medicare	01/15/18
Soliris	Drug Policy	NC Medicare	07/19/17
Soliris	Drug Policy	PA Medicare	07/19/17
Spinraza	Drug Policy	KY Medicare	07/19/17
Spinraza	Drug Policy	NC Medicare	07/19/17
Spinraza	Drug Policy	OH Medicare
Spinraza	Drug Policy	PA Medicare	07/19/17
Subcutaneous Implantable Cardioverter Defibrillator	Medical Policy	KY Medicare	09/15/17
Subcutaneous Implantable Cardioverter Defibrillator	Medical Policy	NC Medicare	09/15/17
Subcutaneous Implantable Cardioverter Defibrillator	Medical Policy	OH Medicare	09/15/17
Subcutaneous Implantable Cardioverter Defibrillator	Medical Policy	PA Medicare	09/15/17
Supervised Exercise Therapy for PAD	Medical Policy	NC Medicare	12/15/2018
Supervised Exercise Therapy for PAD	Medical Policy	OH Medicare	12/15/2018
Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs)	Medical Policy	PA Medicare	04/15/18
Testing of Genetic Disease	Medical Policy	PA Medicare	12/01/17
Tysabri	Drug Policy	KY Medicare	05/01/17
Tysabri	Drug Policy	NC Medicare	05/01/17
Tysabri	Drug Policy	OH Medicare	05/01/17
Tysabri	Drug Policy	PA Medicare	05/01/17
Velcade	Drug Policy	KY Medicare	07/19/17
Velcade	Drug Policy	OH Medicare	07/19/17
Velcade	Drug Policy	PA Medicare	07/19/17
Vimizim	Drug Policy	KY Medicare	05/01/17
Vimizim	Drug Policy	NC Medicare	05/01/17
Vimizim	Drug Policy	OH Medicare	05/01/17
Vimizim	Drug Policy	PA Medicare	05/01/17
Xolair	Drug Policy	KY Medicare	05/01/17
Xolair	Drug Policy	NC Medicare	05/01/17
Xolair	Drug Policy	OH Medicare	05/01/17
Xolair	Drug Policy	PA Medicare	05/01/17
Yervoy	Drug Policy	KY Medicare	05/01/17
Yervoy	Drug Policy	OH Medicare	05/01/17
Yervoy	Drug Policy	PA Medicare	05/01/17
Self-contained Cardiac Pacemakers	Medical Policy	PA Medicare	04/15/2018
Automatic External Defibrillators	Medical Policy	PA Medicare	04/15/2018
Electrocardiographic Services	Medical Policy	PA Medicare	06/01/2018
Electrical Nerve Stimulator	Medical Policy	PA Medicare	04/15/2018
Spinal Cord Stimulation (Dorsal Column Stimulation)	Medical Policy	PA Medicare	06/01/2018
Self-contained Cardiac Pacemakers	Medical Policy	OH Medicare	04/15/2018
Transtelephonic Monitoring	Medical Policy	OH Medicare	04/15/2018
Automatic External Defibrillators	Medical Policy	OH Medicare	04/15/2018
Electrocardiographic Services	Medical Policy	OH Medicare	06/01/2018
Electrical Nerve Stimulator	Medical Policy	OH Medicare	04/15/2018
Self-contained Cardiac Pacemakers	Medical Policy	NC Medicare	04/15/2018
Transtelephonic Monitoring	Medical Policy	NC Medicare	04/15/2018
Automatic External Defibrillators	Medical Policy	NC Medicare	04/15/2018
Electrocardiographic Services	Medical Policy	NC Medicare	06/01/2018
Electrical Nerve Stimulator	Medical Policy	NC Medicare	04/15/2018
Cochlear Implantation	Medical Policy	NC Medicare	04/15/2018
Cochlear Implantation	Medical Policy	OH Medicare	04/15/2018
Cochlear Implantation	Medical Policy	PA Medicare	04/15/2018
Plethysmography	Medical Policy	NC Medicare	04/15/2018
Plethysmography	Medical Policy	OH Medicare	04/15/2018
Plethysmography	Medical Policy	PA Medicare	04/15/2018
TMS	Medical Policy	NC Medicare	04/15/2018
TMS	Medical Policy	OH Medicare	04/15/2018
TMS	Medical Policy	PA Medicare	04/15/2018
Assessing Suitability for Electrical Nerve Stimulation Therapy	Medical Policy	NC Medicare	04/15/2018
Assessing Suitability for Electrical Nerve Stimulation Therapy	Medical Policy	OH Medicare	04/15/2018
Assessing Suitability for Electrical Nerve Stimulation Therapy	Medical Policy	PA Medicare	04/15/2018
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA)	Medical Policy	NC Medicare	06/01/2018
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA)	Medical Policy	PA Medicare	06/01/2018
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA)	Medical Policy	OH Medicare	06/01/2018
CPAP for Obstructive Sleep Apnea (OSA)	Medical Policy	NC Medicare	06/01/2018
CPAP for Obstructive Sleep Apnea (OSA)	Medical Policy	OH Medicare	06/01/2018
CPAP for Obstructive Sleep Apnea (OSA)	Medical Policy	PA Medicare	06/01/2018
Polysomnography and Other Sleep Studies	Medical Policy	NC Medicare	06/01/2018
Polysomnography and Other Sleep Studies	Medical Policy	OH Medicare	06/01/2018
Noninvasive Peripheral Venous Studies	Medical Policy	PA Medicare	06/01/2018
Polysomnography and Other Sleep Studies	Medical Policy	PA Medicare	06/01/2018
Cataract Extraction	Medical Policy	PA Medicare	07/15/2019
Cataract Extraction	Medical Policy	NC Medicare	07/15/2019
Cataract Extraction	Medical Policy	OH Medicare	07/15/2019
Brineura	Drug Policy	OH Medicare	07/15/2019
Brineura	Drug Policy	PA Medicare	07/15/2019
Bronchial Thermoplasty	Medical Policy	NC Medicare	07/15/2019
Pulmonary Rehabilitation	Medical Policy	NC Medicare	07/15/2019
Pulmonary Rehabilitation	Medical Policy	OH Medicare	07/15/2019
Pulmonary Rehabilitation	Medical Policy	PA Medicare	07/15/2019
CV Nuclear Medicine	Medical Policy	OH Medicare	07/15/2019
CV Nuclear Medicine	Medical Policy	PA Medicare	07/15/2019
Cardiac Radionuclide Imaging	Medical Policy	NC Medicare	07/15/2019
Percutaneous Transluminal Angioplasty (PTA)	Medical Policy	NC Medicare	07/15/2019
Percutaneous Transluminal Angioplasty (PTA)	Medical Policy	OH Medicare	07/15/2019
Percutaneous Transluminal Angioplasty (PTA)	Medical Policy	PA Medicare	07/15/2019
Ambulatory Blood Pressure Monitors	Medical Policy	NC Medicare	07/15/2019
Ambulatory Blood Pressure Monitors	Medical Policy	OH Medicare	07/15/2019
Ambulatory Blood Pressure Monitors	Medical Policy	PA Medicare	07/15/2019
Cataract Removal Reimbursement Policy	Medical Policy	PA Medicare	07/15/2018
Cataract Removal Questionnaire	Medical Policy	PA Medicare	07/15/2018
Glucose Monitoring	Medical Policy	NC Medicare	09/01/2018
Glucose Monitoring	Medical Policy	OH Medicare	09/01/2018
Glucose Monitoring	Medical Policy	PA Medicare	09/01/2018
Noninvasive Assessment of Liver Fibrosis	Medical Policy	NC Medicare	09/15/2017
Noninvasive Assessment of Liver Fibrosis	Medical Policy	OH Medicare	09/15/2017
Noninvasive Assessment of Liver Fibrosis	Medical Policy	PA Medicare	09/15/2017
Chromosomal Microarray	Medical Policy	PA Medicare	09/01/2018
Chromosomal Microarray	Medical Policy	NC Medicare	12/01/2017
Chromosomal Microarray	Medical Policy	OH Medicare	09/01/2018
Carpal Tunnel	Medical Policy	NC Medicare	09/15/2018
Carpal Tunnel	Medical Policy	OH Medicare	09/15/2018
Carpal Tunnel	Medical Policy	PA Medicare	09/15/2018
Subcutaneous Implantable Cardioverter Defibrillator	Medical Policy	NC Medicare	09/15/2018
Subcutaneous Implantable Cardioverter Defibrillator	Medical Policy	OH Medicare	09/15/2018
Subcutaneous Implantable Cardioverter Defibrillator	Medical Policy	PA Medicare	09/15/2018
Brineura	Drug Policy	NC Medicare	02/18/2019
Brineura	Drug Policy	OH Medicare	02/18/2019
Brineura	Drug Policy	PA Medicare	02/18/2019
Ambulance (Ground)	Medical Policy	OH Medicare	09/15/2018
Ambulance Services (Air)	Medical Policy	OH Medicare	09/15/2018
Ambulance Services (Ground)	Medical Policy	NC Medicare	09/15/2018
Ambulance Services (Ground)	Medical Policy	PA Medicare	09/15/2018
Ambulance Services(Air)	Medical Policy	PA Medicare	09/15/2018
Implantable Automatic Defibrillators	Medical Policy	NC Medicare	04/15/2018
Implantable Automatic Defibrillators	Medical Policy	OH Medicare	04/15/2018
Implantable Automatic Defibrillators	Medical Policy	PA Medicare	04/15/2018
Noninvasive Technique for the Evaluation of Liver Fibrosis	Medical Policy	OH Medicare	09/01/2018
Noninvasive Technique for the Evaluation of Liver Fibrosis	Medical Policy	KY Medicare	09/01/2018
Noninvasive Technique for the Evaluation of Liver Fibrosis	Medical Policy	NC Medicare	09/01/2018
Noninvasive Technique for the Evaluation of Liver Fibrosis	Medical Policy	PA Medicare	09/01/2018
Spinraza	Drug Policy	NC Medicare	07/15/2018
Spinraza	Drug Policy	OH Medicare	07/15/2018
Botox	Drug Policy	PA Medicare	07/15/2018
Opdivo	Drug Policy	PA Medicare	10/01/2018
Testing of Genetic Disease	Medical Policy	PA Medicare	11/15/2018
Exondys 51	Drug Policy	NC Medicare	07/15/2018
Exondys 51	Drug Policy	OH Medicare	07/15/2018
Exondys 51	Drug Policy	PA Medicare	07/15/2018
Ocrevus	Drug Policy	PA Medicare	07/15/2018
Xolair	Drug Policy	NC Medicare	07/15/2018
Xolair	Drug Policy	OH Medicare	07/15/2018
Xolair	Drug Policy	PA Medicare	07/15/2018
Vimizim	Drug Policy	NC Medicare	07/15/2018
Vimizim	Drug Policy	OH Medicare	07/15/2018
Vimizim	Drug Policy	PA Medicare	07/15/2018
Tysabri	Drug Policy	NC Medicare	07/15/2018
Tysabri	Drug Policy	OH Medicare	07/15/2018
Tysabri	Drug Policy	PA Medicare	07/15/2018
Ocrevus	Drug Policy	KY Medicare	07/15/2018
Ocrevus	Drug Policy	NC Medicare	07/15/2018
Ocrevus	Drug Policy	OH Medicare	07/15/2018
Botox	Drug Policy	NC Medicare	07/15/2018
Adcetris	Drug Policy	PA Medicare	07/15/2018
Portrazza	Drug Policy	PA Medicare	07/15/2018
Alimta	Drug Policy	PA Medicare	07/15/2018
Herceptin	Drug Policy	PA Medicare	07/15/2018
Keytruda	Drug Policy	PA Medicare	07/15/2018
Kyprolis	Drug Policy	PA Medicare	07/15/2018
Rituxan	Drug Policy	PA Medicare	07/15/2018
Pharmacogenomic Testing for Warfarin Response	Medical Policy	PA Medicare	11/15/2018
Faslodex	Drug Policy	PA Medicare	07/15/2018
Perjeta	Drug Policy	PA Medicare	07/15/2018
Yervoy	Drug Policy	PA Medicare	07/15/2018
Hyperbaric Oxygen Therapy	Medical Policy	PA Medicare	12/15/2018
Biomarkers Overview	Medical Policy	PA Medicare	12/15/2018
Supervised Exercise Therapy for PAD	Medical Policy	PA Medicare	12/15/2018
Implantable Cardioverter Defibrillator	Medical Policy	PA Medicare	10/21/2019
G-CSF	Drug Policy	PA Medicare	01/20/2020
Interleukin-5 Inhibitors	Drug Policy	PA Medicare	01/20/2020
Velcade	Drug Policy	PA Medicare	01/20/2020
Home Oxygen Therapy	Medical Policy	PA Medicare	01/20/2020
Remicade	Drug Policy	PA Medicare	02/17/2020
Fecal Transplant	Medical Policy	PA Medicare	02/17/2020
Facility Emergency Department Policy	Medical Payment Policy	PA Medicare	12/31/2019
Soliris	Medical Policy	PA Medicare	03/16/2020
Cardiac Rhythm Device Evaluation	Medical Policy	PA Medicare	03/16/2020
Single and Dual Cardiac Pacemakers	Medical Policy	PA Medicare	03/16/2020
Cataract Extraction	Medical Policy	PA Medicare	04/13/2020
Automatic External Defibrillators	Medical Policy	PA Medicare	04/13/2020
Spinal Cord Stimulation (Dorsal Column Stimulation)	Medical Policy	PA Medicare	04/13/2020
Electrocardiographic Services	Medical Policy	PA Medicare	04/13/2020
Cochlear Implantation	Medical Policy	PA Medicare	05/18/2020
Vitamin D Deficiency	Medical Policy	PA Medicare	08/12/2019
Pulmonary Rehabilitation	Medical Policy	PA Medicare	07/27/2019
CPAP for Obstructive Sleep Apnea (OSA)	Medical Policy	PA Medicare	06/17/2019
Percutaneous Transluminal Angioplasty (PTA)	Medical Policy	PA Medicare	07/15/2019
Noninvasive Venous Studies	Medical Policy	PA Medicare	06/17/2019
Scanning Computerized Ophthalmic Screening	Medical Policy	PA Medicare	07/15/2019
Xolair	Drug Policy	PA Medicare	07/15/2018
Panniculectomy, Abdominoplasty/ Lipectomy	Medical Policy	PA Medicare	08/12/2019
Carpal Tunnel	Medical Policy	PA Medicare	09/16/2019
Home Oxygen Therapy	Medical Policy	PA Medicare	01/20/2020
Ambulatory Blood Pressure Monitors	Medical Policy	PA Medicare	07/15/2019
Ambulance Services(Air)	Medical Policy	PA Medicare	09/16/2019
Negative Pressure Wound Therapy	Medical Policy	PA Medicare	10/21/2019
Observation Care (Hospital Outpatient)	Medical Policy	PA Medicare	10/01/2019
Testing of Genetic Disease	Medical Policy	PA Medicare	10/21/2019
Pharmacogenomic Testing for Warfarin Response	Medical Policy	PA Medicare	11/18/2019
Biomarkers Overview	Medical Policy	PA Medicare	12/09/2019
Hyperbaric Oxygen Therapy	Medical Policy	NC Medicare	12/15/2018
Implantable Cardioverter Defibrillator	Medical Policy	PA Medicare	12/09/2019
Supervised Exercise Therapy for PAD	Medical Policy	NC Medicare	12/15/2018
Cochlear Implantation	Medical Policy	PA Medicare	05/18/2020
Acupuncture for Chronic Low Back Pain (NCD 30.3.3)	Medical Policy	PA Medicare	08/17/2020
Assessing Suitability for Electrical Nerve Stimulation Therapy	Medical Policy	PA Medicare	05/20/2019
Fecal Transplant	Medical Policy	PA Medicare	02/17/2020
Speech Generating Devices	Medical Policy	PA Medicare	02/17/2020
Oral Appliances for Obstructive Sleep Apnea	Medical Policy	PA Medicare	06/19/2019
Leadless Pacemaker	Medical Policy	OH Medicare	03/18/2019
Cardiac Event Detection Monitoring	Medical Policy	PA Medicare	03/16/2020
Esophagogastroduodenoscopy (EGD)	Medical Policy	PA Medicare	03/16/2020
4Kscore	Medical Policy	PA Medicare	03/16/2020
Micro-Invasive Glaucoma Surgery (MIGS)	Medical Policy	PA Medicare	03/16/2020
Peripheral Nerve Stimulation	Medical Policy	PA Medicare	03/16/2020
Cardiac Rhythm Device Evaluation	Medical Policy	PA Medicare	03/16/2020
Single and Dual Cardiac Pacemakers	Medical Policy	PA Medicare	03/16/2020
Glucose Monitoring	Medical Policy	PA Medicare	08/17/2020
Automatic External Defibrillators	Medical Policy	PA Medicare	04/13/2020
Cataract Extraction	Medical Policy	PA Medicare	04/13/2020
Electrocardiographic Services	Medical Policy	PA Medicare	04/13/2020
Gastrointestinal Pathogens Panels	Medical Policy	PA Medicare	04/13/2020
Self-contained Cardiac Pacemakers	Medical Policy	PA Medicare	04/13/2020
Cochlear Implantation (NCD 50.3)	Medical Policy	PA Medicare	01/01/2021
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depression	Medical Policy	PA Medicare	05/18/2020
Pulmonary Rehabilitation	Medical Policy	PA Medicare	07/27/2020
Vitamin D Deficiency	Medical Policy	PA Medicare	06/22/2020
Bronchial Thermoplasty	Medical Policy	PA Medicare	07/27/2020
Percutaneous Transluminal Angioplasty (PTA)	Medical Policy	PA Medicare	07/27/2020
CPAP for Obstructive Sleep Apnea (OSA)	Medical Policy	PA Medicare	07/27/2020
Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) (L35062)	Medical Policy	PA Medicare	08/17/2020
Glucose Monitoring	Medical Policy	PA Medicare	03/15/2021
Ambulance Services (Air)	Medical Policy	OH Medicare	09/16/2019
Ambulatory Blood Pressure Monitors (NCD 20.19)	Medical Policy	PA Medicare	09/07/2020
Carpal Tunnel	Medical Policy	PA Medicare	09/07/2020
Home Oxygen Therapy (L33797)	Medical Policy	PA Medicare	09/07/2020
Panniculectomy, Abdominoplasty/ Lipectomy	Medical Policy	PA Medicare	08/17/2020
Pharmacogenomic Testing for Warfarin Response (NCD 90.1)	Medical Policy	PA Medicare	11/16/2020
Testing of Genetic Disease	Medical Policy	PA Medicare	10/19/2020

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.