Name
Type
State
Effective
Fetal Aneuploidy Medical Policy KY Medicare 07/15/18
Fetal Aneuploidy Medical Policy OH Medicare 07/15/18
Fetal Aneuploidy Medical Policy KY Medicare 08/01/17
Fetal Aneuploidy Medical Policy OH Medicare 08/01/17
Fetal Aneuploidy Medical Policy PA Medicare 07/15/18
Fetal Aneuploidy Medical Policy NC Medicare 08/01/17
Fetal Aneuploidy Medical Policy PA Medicare 08/01/17
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy KY Medicare 10/01/17
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy NC Medicare 10/01/17
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy OH Medicare 10/01/17
Genetic Testing for Colorectal Cancer Susceptibility Medical Policy PA Medicare 10/01/17
Perjeta Medical Policy KY Medicare 09/15/18
Perjeta Medical Policy OH Medicare 09/15/18
Perjeta Drug
Policy
KY Medicare 05/01/17
Perjeta Drug
Policy
OH Medicare 05/01/17
Testing for Genetic Disease Medical Policy KY Medicare 11/15/18
Testing for Genetic Disease Medical Policy NC Medicare 11/15/18
Testing for Genetic Disease Medical Policy OH Medicare 11/15/18
Testing of Genetic Disease Medical Policy KY Medicare 12/01/17
Testing of Genetic Disease Medical Policy NC Medicare 12/01/17
Testing of Genetic Disease Medical Policy OH Medicare 12/01/17
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy KY Medicare 11/15/18
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy NC Medicare 11/15/18
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy PA Medicare 11/15/18
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy OH Medicare 11/15/18
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy KY Medicare 10/01/17
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy NC Medicare 10/01/17
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy OH Medicare 10/01/17
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Medical Policy PA Medicare 10/01/17
Velcade Drug PolicyOH Medicare01/15/2019
G-CSF Drug PolicyKY Medicare01/15/2019
Interleukin-5 Inhibitors Drug PolicyKY Medicare01/15/2019
Velcade Drug PolicyKY Medicare01/15/2019
Home Oxygen Therapy Medical PolicyKY Medicare01/15/2019
Brineura Drug Policy KY Medicare02/18/2019
Fecal Transplant Medical PolicyKY Medicare02/18/2019
Self-contained Cardiac Pacemakers Medical PolicyKY Medicare05/06/2019
Transtelephonic Monitoring Medical PolicyKY Medicare05/06/2019
Automatic External Defibrillators Medical PolicyKY Medicare05/06/2019
Electrocardiographic Services Medical PolicyKY Medicare05/06/2019
Electrical Nerve Stimulator Medical PolicyKY Medicare05/06/2019
Cochlear Implantation Medical PolicyKY Medicare05/20/2019
Plethysmography Medical PolicyKY Medicare05/20/2019
TMS Medical PolicyKY Medicare05/20/2019
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical PolicyKY Medicare05/20/2019
Custom Made Oral Appliances for Obstructive Sleep Apnea (OSA) Medical PolicyKY Medicare06/17/2019
CPAP for Obstructive Sleep Apnea (OSA) Medical PolicyKY Medicare06/17/2019
Polysomnography and Other Sleep Studies Medical PolicyKY Medicare06/17/2019
Pulmonary Rehabilitation Medical PolicyKY Medicare07/15/2019
CV Nuclear Medicine Medical PolicyKY Medicare07/15/2019
Percutaneous Transluminal Angioplasty (PTA) Medical PolicyKY Medicare07/15/2019
Ambulatory Blood Pressure Monitors Medical PolicyKY Medicare07/15/2019
Cataract Extraction Medical PolicyKY Medicare07/15/2019
Bronchial Thermoplasty Medical PolicyKY Medicare07/15/2019
Noninvasive Assessment of Liver Fibrosis Medical PolicyKY Medicare08/12/2019
Chromosomal Microarray Medical PolicyKY Medicare08/12/2019
Glucose Monitoring Medical PolicyKY Medicare08/12/2019
Carpal Tunnel Medical PolicyKY Medicare09/16/2019
Subcutaneous Implantable Cardioverter Defibrillator Medical PolicyKY Medicare09/16/2019
Ambulance (Ground) Medical PolicyKY Medicare09/16/2019
Ambulance Services (Air) Medical PolicyKY Medicare09/16/2019
Exondys 51 Drug PolicyKY Medicare09/16/2019
Tysabri Drug PolicyKY Medicare09/16/2019
Faslodex Drug PolicyKY Medicare09/16/2019
Vimizim Drug PolicyKY Medicare09/16/2019
Spinraza Drug PolicyPA Medicare10/01/2018
Fetal Aneuploidy Medical Policy PA Medicare 10/21/2019
Fetal Aneuploidy Medical Policy NC Medicare 10/21/2019
Implantable Automatic Defibrillators Medical PolicyKY Medicare10/21/2019
Spinraza Drug PolicyKY Medicare11/18/2019
Hyperbaric Oxygen Therapy Medical PolicyKY Medicare11/18/2019
Genetic Testing for Warfarin Therapy Medical PolicyKY Medicare11/18/2019
Implantable Cardioverter Defibrillator Medical PolicyKY Medicare11/18/2019
Upper Gastrointestinal Endoscopy Medical PolicyKY Medicare11/18/2019
Subcutaneous Implantable Cardioverter Defibrillator Medical Policy PA Medicare 12/09/2019
CV Nuclear Medicine Medical PolicyPA Medicare01/20/2020
Noninvasive Liver Assessment Medical Policy PA Medicare 03/16/2020
Electrical Stimulators Medical PolicyPA Medicare03/16/2020
Faslodex Drug PolicyPA Medicare04/13/2020
Herceptin Drug PolicyPA Medicare04/13/2020
G-CSF Drug PolicyPA Medicare04/13/2020
Adcetris Drug PolicyPA Medicare04/13/2020
Kyprolis Drug PolicyPA Medicare04/13/2020
Yervoy Drug PolicyPA Medicare04/13/2020
Keytruda Drug PolicyPA Medicare04/13/2020
Portrazza Drug PolicyPA Medicare04/13/2020
Opdivo Drug PolicyPA Medicare04/13/2020
Perjeta Drug PolicyPA Medicare04/13/2020
Alimta Drug PolicyPA Medicare04/13/2020
Plethysmography Medical PolicyPA Medicare05/18/2020
ADAKVEO Medical Policy PA Medicare 07/01/2020
Exondys 51 Drug PolicyPA Medicare07/01/2020
Tysabri Drug PolicyPA Medicare07/01/2020
Vimizim Drug PolicyPA Medicare 07/01/2020
Spinraza Medical PolicyPA Medicare07/01/2020
Ocrevus Medical PolicyPA Medicare07/01/2020
Rituxan Drug PolicyPA Medicare07/01/2020
Brineura Drug PolicyPA Medicare07/01/2020
Soliris Medical PolicyPA Medicare07/01/2020
Interleukin-5 Inhibitors Drug PolicyPA Medicare01/01/2021
Xolair Drug PolicyPA Medicare01/01/2021
Velcade Drug PolicyPA Medicare 01/01/2021
Botox (OnabotulinumtoxinA) Injections Drug PolicyPA Medicare01/01/2021
Remicade Drug PolicyPA Medicare01/01/2021

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.

Copyright 2021 Gateway Health Plan