Medicare Medical Policy Search

Gateway Health is now part of the Highmark family! We will continue to provide health care to serve the whole you. You can find out how this partnership will impact you here.

Please access the Gateway Health Provider Portal via Navinet to determine if a drug/HCPCS code requires authorization and to submit authorization requests. View drug authorization requirements/submit authorization requests here: https://navinet.navimedix.com.

Name	Type	State	Effective
Adcetris	Drug Policy	KY Medicare	07/15/2018
Adcetris	Drug Policy	OH Medicare	07/15/2018
Alimta	Drug Policy	NC Medicare	07/15/2018
Ambulance (Ground)	Medical Policy	OH Medicare	09/16/2019
Ambulance Services (Air)	Medical Policy	OH Medicare	09/16/2019
Ambulance Services (Air/Ground)	Medical Policy	NC Medicare	09/16/2019
Ambulance Services (Ground) (L35162)	Medical Policy	PA Medicare	09/20/2021
Ambulance Services(Air)	Medical Policy	PA Medicare	09/20/2021
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 (NCD 20.19)	Medical Policy	PA Medicare	09/20/2021
Assessing Suitability for Electrical Nerve Stimulation Therapy	Medical Policy	NC Medicare	05/20/2019
Assessing Suitability for Electrical Nerve Stimulation Therapy	Medical Policy	OH Medicare	05/20/2019
Assessing Patient’s Suitability for Electrical Nerve Stimulation Therapy (160.7.1 & 160.7)	Medical Policy	PA Medicare	02/15/2021
Automatic External Defibrillators	Medical Policy	NC Medicare	05/06/2019
Automatic External Defibrillators	Medical Policy	OH Medicare	05/06/2019
Automatic External Defibrillators(AED) (1.33690)	Medical Policy	PA Medicare	04/19/2021
Biomarkers Overview (L35062)	Medical Policy	PA Medicare	12/21/2020
Brineura	Drug Policy	NC Medicare	09/16/2019
Brineura	Drug Policy	OH Medicare	09/16/2019
Bronchial Thermoplasty	Medical Policy	NC Medicare	07/15/2019
Bronchial Thermoplasty	Medical Policy	PA Medicare	07/19/2021
Bronchial Thermoplasty	Medical Policy	OH Medicare	07/15/2019
Cardiac Event Detection Monitoring	Medical Policy	OH Medicare	03/18/2019
Cardiac Event Detection Monitoring	Medical Policy	NC Medicare	03/18/2019
Cardiac Pacemaker Evaluation Services	Medical Policy	NC Medicare	03/18/2019
Cardiac Pacemaker Evaluation Services	Medical Policy	OH Medicare	03/18/2019
Cardiac Radionuclide Imaging	Medical Policy	NC Medicare	06/01/2018
Cardiac Rhythm Device Evaluation (L34833)	Medical Policy	PA Medicare	03/15/2021
Carpal Tunnel	Medical Policy	NC Medicare	09/16/2019
Carpal Tunnel	Medical Policy	OH Medicare	09/16/2019
Carpal Tunnel	Medical Policy	PA Medicare	09/20/2021
Cataract Extraction (including Complex Cataract Surgery)	Medical Policy	PA Medicare	04/19/2021
Cataract Extraction	Medical Policy	NC Medicare	07/15/2019
Cataract Extraction	Medical Policy	OH Medicare	07/15/2019
Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) (L35062)	Medical Policy	PA Medicare	08/16/2021
Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP)	Medical Policy	NC Medicare	08/12/2019
Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP)	Medical Policy	OH Medicare	08/12/2019
Cochlear Implantation	Medical Policy	NC Medicare	05/20/2019
Cochlear Implantation	Medical Policy	OH Medicare	05/20/2019
Cochlear Implantation (NCD 50.3)	Medical Policy	PA Medicare	05/17/2021
CPAP for Obstructive Sleep Apnea (OSA)	Medical Policy	NC Medicare	06/17/2019
CPAP for Obstructive Sleep Apnea (OSA)	Medical Policy	OH Medicare	06/17/2019
CV Nuclear Medicine	Medical Policy	OH Medicare	07/15/2019
Electrical Nerve Stimulator	Medical Policy	NC Medicare	05/06/2019
Electrical Nerve Stimulator	Medical Policy	OH Medicare	05/06/2019
Electrocardiographic Services	Medical Policy	NC Medicare	05/06/2019
Electrocardiographic Services	Medical Policy	OH Medicare	05/06/2019
Electrocardiographic Services(NCD 20.15)	Medical Policy	PA Medicare	04/19/2021
Esophagogastroduodenoscopy (EGD)	Medical Policy	NC Medicare	08/01/2018
Esophagogastroduodenoscopy (EGD)	Medical Policy	OH Medicare	08/01/2018
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)(L35350)	Medical Policy	PA Medicare	03/15/2021
Exondys 51	Drug Policy	NC Medicare	10/21/2019
Exondys 51	Drug Policy	OH Medicare	10/21/2019
Faslodex	Drug Policy	NC Medicare	07/15/2018
Faslodex	Drug Policy	OH Medicare	07/15/2018
Fecal Transplant	Medical Policy	NC Medicare	02/18/2019
Fecal Microbiota Transplant	Medical Policy	PA Medicare	02/15/2021
Fecal Transplant	Medical Policy	OH Medicare	02/18/2019
G-CSF	Drug Policy	OH Medicare	01/15/2019
G-CSF	Drug Policy	NC Medicare	01/15/2019
Glucose Monitoring	Medical Policy	NC Medicare	08/12/2019
Glucose Monitoring	Medical Policy	OH Medicare	08/12/2019
Glucose Monitoring (L33822)	Medical Policy	PA Medicare	08/16/2021
Home Oxygen Therapy	Medical Policy	NC Medicare	01/15/2019
Home Oxygen Therapy	Medical Policy	OH Medicare	01/15/2019
Home Oxygen Therapy (L33797)	Medical Policy	PA Medicare	09/20/2021
Hyperbaric Oxygen Therapy (NCD 20.29)	Medical Policy	NC Medicare	12/21/2020
Hyperbaric Oxygen Therapy	Medical Policy	OH Medicare	12/15/2018
Hyperbaric Oxygen Therapy	Medical Policy	PA Medicare	12/09/2019
Interleukin-5 Inhibitors	Drug Policy	NC Medicare	01/15/2019
Interleukin-5 Inhibitors	Drug Policy	OH Medicare	01/15/2019
Leadless Pacemaker	Medical Policy	NC Medicare	03/18/2019
Leadless Pacemaker	Medical Policy	OH Medicare	03/18/2019
Leadless Pacemaker (NCD 20.8.4)	Medical Policy	PA Medicare	03/15/2021
MolDX: Molecular Diagnostic Tests	Medical Policy	NC Medicare	12/15/2018
MolDX: Molecular Diagnostic Tests	Medical Policy	OH Medicare	12/15/2018
Noninvasive Assessment of Liver Fibrosis	Medical Policy	NC Medicare	08/12/2019
Noninvasive Assessment of Liver Fibrosis	Medical Policy	OH Medicare	08/12/2019
Noninvasive Venous Studies	Medical Policy	KY Medicare	06/01/2018
Noninvasive Venous Studies	Medical Policy	OH Medicare	06/01/2018
Percutaneous Transluminal Angioplasty (PTA)	Medical Policy	NC Medicare	07/15/2019
Percutaneous Transluminal Angioplasty (PTA)	Medical Policy	OH Medicare	07/15/2019
Perjeta	Drug Policy	NC Medicare	07/15/2018
Pharmacogenomic Testing for Warfarin Response (NCD 90.1)	Medical Policy	PA Medicare	11/15/2021
Pharmacogenomic Testing for Warfarin Response	Medical Policy	NC Medicare	11/15/2018
Pharmacogenomic Testing for Warfarin Response	Medical Policy	OH Medicare	11/15/2018
Plethysmography	Medical Policy	NC Medicare	05/20/2019
Plethysmography	Medical Policy	OH Medicare	05/20/2019
Outpatient Sleep Studies	Medical Policy	PA Medicare	07/27/2020
Outpatient Sleep Studies	Medical Policy	NC Medicare	06/17/2019
Outpatient Sleep Studies	Medical Policy	OH Medicare	06/17/2019
Pulmonary Rehabilitation	Medical Policy	NC Medicare	07/15/2019
Pulmonary Rehabilitation	Medical Policy	OH Medicare	07/15/2019
Self-contained Cardiac Pacemakers	Medical Policy	NC Medicare	05/06/2019
Self-contained Cardiac Pacemakers	Medical Policy	OH Medicare	05/06/2019
Self-Contained Pacemaker Monitors (NCD 20.82)	Medical Policy	PA Medicare	04/19/2021
Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (NCD 20.8.3)	Medical Policy	PA Medicare	03/15/2021
Single and Dual Cardiac Pacemakers	Medical Policy	NC Medicare	03/18/2019
Single and Dual Cardiac Pacemakers	Medical Policy	OH Medicare	03/18/2019
Soliris	Drug Policy	NC Medicare	01/15/2018
Spinal Cord Stimulation (Dorsal Column Stimulation)(1.35450)	Medical Policy	PA Medicare	04/19/2021
Spinal Cord Stimulators for Chronic Pain	Medical Policy	NC Medicare	06/01/2018
Spinraza	Drug Policy	NC Medicare	10/21/2019
Spinraza	Drug Policy	OH Medicare	10/21/2019
Subcutaneous Implantable Cardioverter Defibrillator	Medical Policy	NC Medicare	09/16/2019
Subcutaneous Implantable Cardioverter Defibrillator	Medical Policy	OH Medicare	09/16/2019
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (NCD 20.35)	Medical Policy	NC Medicare	12/21/2020
Supervised Exercise Therapy for PAD	Medical Policy	OH Medicare	12/15/2018
Supervised Exercise Therapy for PAD	Medical Policy	PA Medicare	12/09/2019
Surveillance of Implantable or Wearable Cardioverter Defibrillators	Medical Policy	NC Medicare	03/18/2019
Surveillance of Implantable or Wearable Cardioverter Defibrillators	Medical Policy	OH Medicare	03/18/2019
Cardiac Event Detection Monitoring (L34953)	Medical Policy	PA Medicare	03/15/2021
Testing of Genetic Disease	Medical Policy	PA Medicare	11/15/2021
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depression	Medical Policy	NC Medicare	05/20/2019
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depression	Medical Policy	OH Medicare	05/20/2019
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depression (LCD 34998)	Medical Policy	PA Medicare	05/17/2021
Transtelephonic Monitoring	Medical Policy	NC Medicare	05/06/2019
Transtelephonic Monitoring	Medical Policy	OH Medicare	05/06/2019
Tysabri	Drug Policy	NC Medicare	10/21/2019
Tysabri	Drug Policy	OH Medicare	10/21/2019
Velcade	Drug Policy	NC Medicare	01/15/2019
Vimizim	Drug Policy	NC Medicare	10/21/2019
Vimizim	Drug Policy	OH Medicare	10/21/2019
Xolair	Drug Policy	KY Medicare	07/15/2018
Xolair	Drug Policy	NC Medicare	10/21/2019
Xolair	Drug Policy	OH Medicare	10/21/2019
Yervoy	Drug Policy	KY Medicare	07/15/2018
Yervoy	Drug Policy	OH Medicare	07/15/2018
Scanning Computerized Ophthalmic Diagnostic Imaging	Medical Policy	OH Medicare	07/15/2019
Scanning Computerized Ophthalmic Diagnostic Imaging	Medical Policy	NC Medicare	07/15/2019
Cosmetic and Reconstructive Surgery (L35090)	Medical Policy	PA Medicare	09/20/2021
Vitamin D Deficiency	Medical Policy	OH Medicare	08/12/2019
Panniculectomy, Abdominoplasty/ Lipectomy	Medical Policy	OH Medicare	08/12/2019
Vitamin D Deficiency	Medical Policy	NC Medicare	08/12/2019
Panniculectomy, Abdominoplasty/ Lipectomy	Medical Policy	NC Medicare	08/12/2019
Observation Care (Hospital Outpatient)	Medical Policy	PA Medicare	10/18/2021
Negative Pressure Wound Therapy (NPWT) Pumps (L33821)	Medical Policy	PA Medicare	10/18/2021
Negative Pressure Wound Therapy	Medical Policy	OH Medicare	10/21/2019
Negative Pressure Wound Therapy	Medical Policy	NC Medicare	10/21/2019
Implantable Cardioverter Defibrillator (NCD 20.4)	Medical Policy	PA Medicare	12/21/2020
Noninvasive Vascular Studies	Medical Policy	OH Medicare	10/21/2019
Ocrevus	Medical Policy	NC Medicare	10/21/2019
Ocrevus	Medical Policy	OH Medicare	10/21/2019
Implantable Cardioverter Defibrillator	Medical Policy	NC Medicare	10/21/2019
Implantable Cardioverter Defibrillator	Medical Policy	OH Medicare	10/21/2019
Botox	Medical Policy	NC Medicare	10/21/2019
Speech Generating Devices (L33739)	Medical Policy	PA Medicare	02/15/2021
4Kscore Test Algorithm(L37792)	Medical Policy	PA Medicare	03/15/2021
Micro-Invasive Glaucoma Surgery (MIGS)(L38223)	Medical Policy	PA Medicare	03/15/2021
Peripheral Nerve Stimulation(L37360)(160.7)	Medical Policy	PA Medicare	03/15/2021
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (1.38229)	Medical Policy	PA Medicare	04/19/2021
Hypoglossal Stimulation for the Treatment of Obstructive Sleep Apnea	Medical Policy	PA Medicare	04/13/2020
Pulmonary Rehabilitation	Medical Policy	PA Medicare	07/19/2021
CPAP for Obstructive Sleep Apnea (OSA)	Medical Policy	PA Medicare	07/27/2020
Percutaneous Transluminal Angioplasty (PTA) (NCD 20.7)	Medical Policy	PA Medicare	07/19/2021
Non-Invasive Peripheral Venous Studies (L35451)	Medical Policy	PA Medicare	07/27/2020
Scanning Computerized Ophthalmic Diagnostic Imaging	Medical Policy	PA Medicare	07/27/2020
Acupuncture for Chronic Low Back Pain (NCD 30.3.3)	Medical Policy	PA Medicare	01/01/2021
Implantable Continuous Glucose Monitors (I-CGM) (L38617)	Medical Policy	PA Medicare	01/18/2021
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (L38495)	Medical Policy	PA Medicare	01/18/2021
Blood Glucose Testing (NCD 190.20)	Medical Policy	PA Medicare	02/15/2021
Oral Appliances for Obstructive Sleep Apnea (L33611)	Medical Policy	PA Medicare	02/15/2021
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (1.38385)	Medical Policy	PA Medicare	04/19/2021
Vitamin D Deficiency Screening	Medical Policy	PA Medicare	06/21/2021
Osteogenic Stimulators (150.2)	Medical Policy	PA Medicare	11/15/2021

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.