Medicare Medical Policy Archive Search



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 PolicyPA Medicare06/01/2018
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 PolicyNC Medicare12/15/2018
Supervised Exercise Therapy for PAD Medical PolicyOH Medicare12/15/2018
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 PolicyPA Medicare04/15/2018
Automatic External Defibrillators Medical PolicyPA Medicare04/15/2018
Electrocardiographic Services Medical PolicyPA Medicare06/01/2018
Electrical Nerve Stimulator Medical PolicyPA Medicare04/15/2018
Spinal Cord Stimulation (Dorsal Column Stimulation) Medical PolicyPA Medicare06/01/2018
Self-contained Cardiac Pacemakers Medical PolicyOH Medicare04/15/2018
Transtelephonic Monitoring Medical PolicyOH Medicare04/15/2018
Automatic External Defibrillators Medical PolicyOH Medicare04/15/2018
Electrocardiographic Services Medical PolicyOH Medicare06/01/2018
Electrical Nerve Stimulator Medical PolicyOH Medicare04/15/2018
Self-contained Cardiac Pacemakers Medical PolicyNC Medicare04/15/2018
Transtelephonic Monitoring Medical PolicyNC Medicare04/15/2018
Automatic External Defibrillators Medical PolicyNC Medicare04/15/2018
Electrocardiographic Services Medical PolicyNC Medicare06/01/2018
Electrical Nerve Stimulator Medical PolicyNC Medicare04/15/2018
Cochlear Implantation Medical PolicyNC Medicare04/15/2018
Cochlear Implantation Medical PolicyOH Medicare04/15/2018
Cochlear Implantation Medical PolicyPA Medicare04/15/2018
Plethysmography Medical PolicyNC Medicare04/15/2018
Plethysmography Medical PolicyOH Medicare04/15/2018
Plethysmography Medical PolicyPA Medicare04/15/2018
TMS Medical PolicyNC Medicare 04/15/2018
TMS Medical PolicyOH Medicare04/15/2018
TMS Medical PolicyPA Medicare04/15/2018
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical PolicyNC Medicare 04/15/2018
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical PolicyOH Medicare04/15/2018
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical PolicyPA Medicare04/15/2018
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA) Medical PolicyNC Medicare06/01/2018
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA) Medical PolicyPA Medicare06/01/2018
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA) Medical PolicyOH Medicare06/01/2018
CPAP for Obstructive Sleep Apnea (OSA) Medical PolicyNC Medicare06/01/2018
CPAP for Obstructive Sleep Apnea (OSA) Medical PolicyOH Medicare06/01/2018
CPAP for Obstructive Sleep Apnea (OSA) Medical PolicyPA Medicare06/01/2018
Polysomnography and Other Sleep Studies Medical PolicyNC Medicare06/01/2018
Polysomnography and Other Sleep Studies Medical PolicyOH Medicare06/01/2018
Noninvasive Peripheral Venous Studies Medical PolicyPA Medicare06/01/2018
Polysomnography and Other Sleep Studies Medical PolicyPA Medicare06/01/2018
Cataract Extraction Medical PolicyPA Medicare07/15/2019
Cataract Extraction Medical PolicyNC Medicare07/15/2019
Cataract Extraction Medical PolicyOH Medicare07/15/2019
Brineura Drug PolicyOH Medicare07/15/2019
Brineura Drug PolicyPA Medicare07/15/2019
Bronchial Thermoplasty Medical PolicyNC Medicare07/15/2019
Pulmonary Rehabilitation Medical PolicyNC Medicare07/15/2019
Pulmonary Rehabilitation Medical PolicyOH Medicare07/15/2019
Pulmonary Rehabilitation Medical PolicyPA Medicare07/15/2019
CV Nuclear Medicine Medical PolicyOH Medicare07/15/2019
CV Nuclear Medicine Medical PolicyPA Medicare07/15/2019
Cardiac Radionuclide Imaging Medical PolicyNC Medicare07/15/2019
Percutaneous Transluminal Angioplasty (PTA) Medical PolicyNC Medicare07/15/2019
Percutaneous Transluminal Angioplasty (PTA) Medical PolicyOH Medicare07/15/2019
Percutaneous Transluminal Angioplasty (PTA) Medical PolicyPA Medicare07/15/2019
Ambulatory Blood Pressure Monitors Medical PolicyNC Medicare07/15/2019
Ambulatory Blood Pressure Monitors Medical PolicyOH Medicare07/15/2019
Ambulatory Blood Pressure Monitors Medical PolicyPA Medicare07/15/2019
Cataract Removal Reimbursement Policy Medical PolicyPA Medicare07/15/2018
Cataract Removal Questionnaire Medical PolicyPA Medicare07/15/2018
Glucose Monitoring Medical PolicyNC Medicare09/01/2018
Glucose Monitoring Medical PolicyOH Medicare09/01/2018
Glucose Monitoring Medical PolicyPA Medicare09/01/2018
Noninvasive Assessment of Liver Fibrosis Medical PolicyNC Medicare09/15/2017
Noninvasive Assessment of Liver Fibrosis Medical PolicyOH Medicare09/15/2017
Noninvasive Assessment of Liver Fibrosis Medical PolicyPA Medicare09/15/2017
Chromosomal Microarray Medical PolicyPA Medicare09/01/2018
Chromosomal Microarray Medical PolicyNC Medicare12/01/2017
Chromosomal Microarray Medical PolicyOH Medicare09/01/2018
Carpal Tunnel Medical PolicyNC Medicare09/15/2018
Carpal Tunnel Medical PolicyOH Medicare09/15/2018
Carpal Tunnel Medical PolicyPA Medicare09/15/2018
Subcutaneous Implantable Cardioverter Defibrillator Medical PolicyNC Medicare09/15/2018
Subcutaneous Implantable Cardioverter Defibrillator Medical PolicyOH Medicare09/15/2018
Subcutaneous Implantable Cardioverter Defibrillator Medical PolicyPA Medicare09/15/2018
Brineura Drug PolicyNC Medicare02/18/2019
Brineura Drug PolicyOH Medicare02/18/2019
Brineura Drug PolicyPA Medicare02/18/2019
Ambulance (Ground) Medical PolicyOH Medicare09/15/2018
Ambulance Services (Air) Medical PolicyOH Medicare09/15/2018
Ambulance Services (Ground) Medical PolicyNC Medicare09/15/2018
Ambulance Services (Ground) Medical PolicyPA Medicare09/15/2018
Ambulance Services(Air) Medical PolicyPA Medicare09/15/2018
Implantable Automatic Defibrillators Medical PolicyNC Medicare04/15/2018
Implantable Automatic Defibrillators Medical PolicyOH Medicare04/15/2018
Implantable Automatic Defibrillators Medical PolicyPA Medicare04/15/2018
Noninvasive Technique for the Evaluation of Liver Fibrosis Medical PolicyOH Medicare09/01/2018
Noninvasive Technique for the Evaluation of Liver Fibrosis Medical PolicyKY Medicare09/01/2018
Noninvasive Technique for the Evaluation of Liver Fibrosis Medical PolicyNC Medicare09/01/2018
Noninvasive Technique for the Evaluation of Liver Fibrosis Medical PolicyPA Medicare09/01/2018
Spinraza Drug PolicyNC Medicare07/15/2018
Spinraza Drug PolicyOH Medicare07/15/2018
Botox Drug PolicyPA Medicare07/15/2018
Opdivo Drug PolicyPA Medicare10/01/2018
Testing of Genetic Disease Medical PolicyPA Medicare11/15/2018
Exondys 51 Drug PolicyNC Medicare07/15/2018
Exondys 51 Drug PolicyOH Medicare07/15/2018
Exondys 51 Drug PolicyPA Medicare07/15/2018
Ocrevus Drug PolicyPA Medicare07/15/2018
Xolair Drug PolicyNC Medicare07/15/2018
Xolair Drug PolicyOH Medicare07/15/2018
Xolair Drug PolicyPA Medicare07/15/2018
Vimizim Drug PolicyNC Medicare07/15/2018
Vimizim Drug PolicyOH Medicare07/15/2018
Vimizim Drug PolicyPA Medicare07/15/2018
Tysabri Drug PolicyNC Medicare07/15/2018
Tysabri Drug PolicyOH Medicare07/15/2018
Tysabri Drug PolicyPA Medicare07/15/2018
Ocrevus Drug PolicyKY Medicare07/15/2018
Ocrevus Drug PolicyNC Medicare07/15/2018
Ocrevus Drug PolicyOH Medicare07/15/2018
Botox Drug PolicyNC Medicare07/15/2018
Adcetris Drug PolicyPA Medicare07/15/2018
Portrazza Drug PolicyPA Medicare07/15/2018
Alimta Drug PolicyPA Medicare07/15/2018
Herceptin Drug PolicyPA Medicare07/15/2018
Keytruda Drug PolicyPA Medicare07/15/2018
Kyprolis Drug PolicyPA Medicare07/15/2018
Rituxan Drug PolicyPA Medicare07/15/2018
Pharmacogenomic Testing for Warfarin Response Medical PolicyPA Medicare11/15/2018
Faslodex Drug PolicyPA Medicare07/15/2018
Perjeta Drug PolicyPA Medicare07/15/2018
Yervoy Drug PolicyPA Medicare07/15/2018
Hyperbaric Oxygen Therapy Medical PolicyPA Medicare12/15/2018
Biomarkers Overview Medical PolicyPA Medicare12/15/2018
Supervised Exercise Therapy for PAD Medical PolicyPA Medicare12/15/2018
Implantable Cardioverter Defibrillator Medical PolicyPA Medicare10/21/2019
G-CSF Drug PolicyPA Medicare01/20/2020
Interleukin-5 Inhibitors Drug PolicyPA Medicare01/20/2020
Velcade Drug PolicyPA Medicare01/20/2020
Home Oxygen Therapy Medical PolicyPA Medicare01/20/2020
Remicade Drug PolicyPA Medicare02/17/2020
Fecal Transplant Medical PolicyPA Medicare02/17/2020
Facility Emergency Department Policy Medical Payment PolicyPA Medicare12/31/2019
Soliris Medical PolicyPA Medicare03/16/2020
Cardiac Rhythm Device Evaluation Medical PolicyPA Medicare03/16/2020
Single and Dual Cardiac Pacemakers Medical PolicyPA Medicare03/16/2020
Cataract Extraction Medical PolicyPA Medicare04/13/2020
Automatic External Defibrillators Medical PolicyPA Medicare 04/13/2020
Spinal Cord Stimulation (Dorsal Column Stimulation) Medical PolicyPA Medicare 04/13/2020
Electrocardiographic Services Medical PolicyPA Medicare 04/13/2020
Cochlear Implantation Medical PolicyPA Medicare05/18/2020
Vitamin D Deficiency Medical PolicyPA Medicare08/12/2019
Pulmonary Rehabilitation Medical PolicyPA Medicare07/27/2019
CPAP for Obstructive Sleep Apnea (OSA) Medical PolicyPA Medicare06/17/2019
Percutaneous Transluminal Angioplasty (PTA) Medical PolicyPA Medicare07/15/2019
Noninvasive Venous Studies Medical PolicyPA Medicare06/17/2019
Scanning Computerized Ophthalmic Screening Medical PolicyPA Medicare07/15/2019
Xolair Drug PolicyPA Medicare07/15/2018
Panniculectomy, Abdominoplasty/ Lipectomy Medical PolicyPA Medicare08/12/2019
Carpal Tunnel Medical PolicyPA Medicare09/16/2019
Home Oxygen Therapy Medical PolicyPA Medicare01/20/2020
Ambulatory Blood Pressure Monitors Medical PolicyPA Medicare07/15/2019
Ambulance Services(Air) Medical PolicyPA Medicare09/16/2019
Negative Pressure Wound Therapy Medical Policy PA Medicare 10/21/2019
Observation Care (Hospital Outpatient) Medical PolicyPA Medicare10/01/2019
Testing of Genetic Disease Medical PolicyPA Medicare10/21/2019
Pharmacogenomic Testing for Warfarin Response Medical PolicyPA Medicare11/18/2019
Biomarkers Overview Medical PolicyPA Medicare12/09/2019
Hyperbaric Oxygen Therapy Medical PolicyNC Medicare12/15/2018
Implantable Cardioverter Defibrillator Medical PolicyPA Medicare12/09/2019
Supervised Exercise Therapy for PAD Medical PolicyNC Medicare12/15/2018
Cochlear Implantation Medical PolicyPA Medicare05/18/2020
Acupuncture for Chronic Low Back Pain
(NCD 30.3.3)
Medical PolicyPA Medicare08/17/2020
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical PolicyPA Medicare05/20/2019
Fecal Transplant Medical PolicyPA Medicare 02/17/2020
Speech Generating Devices Medical Policy PA Medicare 02/17/2020
Oral Appliances for Obstructive Sleep Apnea Medical PolicyPA Medicare06/19/2019
Leadless Pacemaker Medical PolicyOH Medicare03/18/2019
Cardiac Event Detection Monitoring Medical PolicyPA Medicare03/16/2020
Esophagogastroduodenoscopy (EGD) Medical PolicyPA Medicare03/16/2020
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 PolicyPA Medicare03/16/2020
Single and Dual Cardiac Pacemakers Medical PolicyPA Medicare03/16/2020
Glucose Monitoring Medical PolicyPA Medicare08/17/2020
Automatic External Defibrillators Medical PolicyPA Medicare 04/13/2020
Cataract Extraction Medical PolicyPA Medicare04/13/2020
Electrocardiographic Services Medical PolicyPA Medicare 04/13/2020
Gastrointestinal Pathogens Panels Medical Policy PA Medicare 04/13/2020
Self-contained Cardiac Pacemakers Medical PolicyPA Medicare 04/13/2020
Cochlear Implantation (NCD 50.3) Medical PolicyPA Medicare01/01/2021
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depression Medical PolicyPA Medicare05/18/2020
Pulmonary Rehabilitation Medical PolicyPA Medicare07/27/2020

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  • 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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