Medicare Medical Policy Search



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Name
Type
State
Effective
Adcetris Drug PolicyKY Medicare07/15/2018
Adcetris Drug PolicyOH Medicare07/15/2018
Alimta Drug PolicyNC Medicare07/15/2018
Ambulance (Ground) Medical PolicyOH Medicare09/16/2019
Ambulance Services (Air) Medical PolicyOH Medicare09/16/2019
Ambulance Services (Air/Ground) Medical PolicyNC Medicare 09/16/2019
Ambulance Services (Ground) (L35162) Medical PolicyPA Medicare 09/07/2020
Ambulance Services(Air) Medical PolicyPA Medicare09/07/2020
Ambulatory Blood Pressure Monitors Medical PolicyNC Medicare07/15/2019
Ambulatory Blood Pressure Monitors Medical PolicyOH Medicare07/15/2019
Ambulatory Blood Pressure Monitors (NCD 20.19) Medical PolicyPA Medicare09/07/2020
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical PolicyNC Medicare05/20/2019
Assessing Suitability for Electrical Nerve Stimulation Therapy Medical PolicyOH Medicare05/20/2019
Assessing Patient’s Suitability for Electrical Nerve Stimulation Therapy (160.7.1 & 160.7) Medical PolicyPA Medicare02/15/2021
Automatic External Defibrillators Medical PolicyNC Medicare 05/06/2019
Automatic External Defibrillators Medical PolicyOH Medicare 05/06/2019
Automatic External Defibrillators(AED) (1.33690) Medical PolicyPA Medicare 04/19/2021
Biomarkers Overview (L35062) Medical PolicyPA Medicare12/21/2020
Brineura Drug PolicyNC Medicare09/16/2019
Brineura Drug PolicyOH Medicare09/16/2019
Bronchial Thermoplasty Medical PolicyNC Medicare07/15/2019
Bronchial Thermoplasty Medical PolicyPA Medicare07/19/2021
Bronchial Thermoplasty Medical PolicyOH Medicare07/15/2019
Cardiac Event Detection Monitoring Medical PolicyOH Medicare03/18/2019
Cardiac Event Detection Monitoring Medical PolicyNC Medicare03/18/2019
Cardiac Pacemaker Evaluation Services Medical PolicyNC Medicare03/18/2019
Cardiac Pacemaker Evaluation Services Medical PolicyOH Medicare03/18/2019
Cardiac Radionuclide Imaging Medical PolicyNC Medicare06/01/2018
Cardiac Rhythm Device Evaluation (L34833) Medical PolicyPA Medicare03/15/2021
Carpal Tunnel Medical PolicyNC Medicare09/16/2019
Carpal Tunnel Medical PolicyOH Medicare09/16/2019
Carpal Tunnel Medical PolicyPA Medicare09/07/2020
Cataract Extraction (including Complex Cataract Surgery) Medical PolicyPA Medicare04/19/2021
Cataract Extraction Medical PolicyNC Medicare07/15/2019
Cataract Extraction Medical PolicyOH Medicare07/15/2019
Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) (L35062) Medical PolicyPA Medicare08/16/2021
Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) Medical PolicyNC Medicare08/12/2019
Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) Medical PolicyOH Medicare08/12/2019
Cochlear Implantation Medical PolicyNC Medicare05/20/2019
Cochlear Implantation Medical PolicyOH Medicare05/20/2019
Cochlear Implantation (NCD 50.3) Medical PolicyPA Medicare05/17/2021
CPAP for Obstructive Sleep Apnea (OSA) Medical PolicyNC Medicare06/17/2019
CPAP for Obstructive Sleep Apnea (OSA) Medical PolicyOH Medicare06/17/2019
CV Nuclear Medicine Medical PolicyOH Medicare07/15/2019
Electrical Nerve Stimulator Medical PolicyNC Medicare05/06/2019
Electrical Nerve Stimulator Medical PolicyOH Medicare 05/06/2019
Electrocardiographic Services Medical PolicyNC Medicare 05/06/2019
Electrocardiographic Services Medical PolicyOH Medicare 05/06/2019
Electrocardiographic Services(NCD 20.15) Medical PolicyPA Medicare 04/19/2021
Esophagogastroduodenoscopy (EGD) Medical PolicyNC Medicare08/01/2018
Esophagogastroduodenoscopy (EGD) Medical PolicyOH Medicare08/01/2018
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)(L35350) Medical PolicyPA Medicare03/15/2021
Exondys 51 Drug PolicyNC Medicare10/21/2019
Exondys 51 Drug PolicyOH Medicare10/21/2019
Faslodex Drug PolicyNC Medicare07/15/2018
Faslodex Drug PolicyOH Medicare07/15/2018
Fecal Transplant Medical PolicyNC Medicare02/18/2019
Fecal Microbiota Transplant Medical PolicyPA Medicare 02/15/2021
Fecal Transplant Medical PolicyOH Medicare02/18/2019
G-CSF Drug PolicyOH Medicare01/15/2019
G-CSF Drug PolicyNC Medicare01/15/2019
Glucose Monitoring Medical PolicyNC Medicare08/12/2019
Glucose Monitoring Medical PolicyOH Medicare08/12/2019
Glucose Monitoring (L33822) Medical PolicyPA Medicare08/16/2021
Home Oxygen Therapy Medical PolicyNC Medicare01/15/2019
Home Oxygen Therapy Medical PolicyOH Medicare01/15/2019
Home Oxygen Therapy (L33797) Medical PolicyPA Medicare09/07/2020
Hyperbaric Oxygen Therapy (NCD 20.29) Medical PolicyNC Medicare12/21/2020
Hyperbaric Oxygen Therapy Medical PolicyOH Medicare12/15/2018
Hyperbaric Oxygen Therapy Medical PolicyPA Medicare12/09/2019
Interleukin-5 Inhibitors Drug PolicyNC Medicare01/15/2019
Interleukin-5 Inhibitors Drug PolicyOH Medicare01/15/2019
Leadless Pacemaker Medical PolicyNC Medicare03/18/2019
Leadless Pacemaker Medical PolicyOH Medicare03/18/2019
Leadless Pacemaker (NCD 20.8.4) Medical PolicyPA Medicare03/15/2021
MolDX: Molecular Diagnostic Tests Medical PolicyNC Medicare12/15/2018
MolDX: Molecular Diagnostic Tests Medical PolicyOH Medicare12/15/2018
Noninvasive Assessment of Liver Fibrosis Medical PolicyNC Medicare08/12/2019
Noninvasive Assessment of Liver Fibrosis Medical PolicyOH Medicare08/12/2019
Noninvasive Venous Studies Medical PolicyKY Medicare06/01/2018
Noninvasive Venous Studies Medical PolicyOH Medicare06/01/2018
Percutaneous Transluminal Angioplasty (PTA) Medical PolicyNC Medicare07/15/2019
Percutaneous Transluminal Angioplasty (PTA) Medical PolicyOH Medicare07/15/2019
Perjeta Drug PolicyNC Medicare07/15/2018
Pharmacogenomic Testing for Warfarin Response (NCD 90.1) Medical PolicyPA Medicare11/16/2020
Pharmacogenomic Testing for Warfarin Response Medical PolicyNC Medicare11/15/2018
Pharmacogenomic Testing for Warfarin Response Medical PolicyOH Medicare11/15/2018
Plethysmography Medical PolicyNC Medicare05/20/2019
Plethysmography Medical PolicyOH Medicare05/20/2019
Outpatient Sleep Studies Medical PolicyPA Medicare 07/27/2020
Outpatient Sleep Studies Medical PolicyNC Medicare06/17/2019
Outpatient Sleep Studies Medical PolicyOH Medicare06/17/2019
Pulmonary Rehabilitation Medical PolicyNC Medicare07/15/2019
Pulmonary Rehabilitation Medical PolicyOH Medicare07/15/2019
Self-contained Cardiac Pacemakers Medical PolicyNC Medicare 05/06/2019
Self-contained Cardiac Pacemakers Medical PolicyOH Medicare 05/06/2019
Self-Contained Pacemaker Monitors (NCD 20.82) Medical PolicyPA Medicare 04/19/2021
Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (NCD 20.8.3) Medical PolicyPA Medicare03/15/2021
Single and Dual Cardiac Pacemakers Medical PolicyNC Medicare03/18/2019
Single and Dual Cardiac Pacemakers Medical PolicyOH Medicare03/18/2019
Soliris Drug PolicyNC Medicare01/15/2018
Spinal Cord Stimulation (Dorsal Column Stimulation)(1.35450) Medical PolicyPA Medicare 04/19/2021
Spinal Cord Stimulators for Chronic Pain Medical PolicyNC Medicare06/01/2018
Spinraza Drug PolicyNC Medicare10/21/2019
Spinraza Drug PolicyOH Medicare10/21/2019
Subcutaneous Implantable Cardioverter Defibrillator Medical PolicyNC Medicare09/16/2019
Subcutaneous Implantable Cardioverter Defibrillator Medical PolicyOH Medicare09/16/2019
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (NCD 20.35) Medical PolicyNC Medicare12/21/2020
Supervised Exercise Therapy for PAD Medical PolicyOH Medicare12/15/2018
Supervised Exercise Therapy for PAD Medical PolicyPA Medicare12/09/2019
Surveillance of Implantable or Wearable Cardioverter Defibrillators Medical PolicyNC Medicare03/18/2019
Surveillance of Implantable or Wearable Cardioverter Defibrillators Medical PolicyOH Medicare03/18/2019
Cardiac Event Detection Monitoring (L34953) Medical PolicyPA Medicare03/15/2021
Testing of Genetic Disease Medical PolicyPA Medicare10/19/2020
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depression Medical PolicyNC Medicare05/20/2019
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depression Medical PolicyOH Medicare05/20/2019
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depression (LCD 34998) Medical PolicyPA Medicare05/17/2021
Transtelephonic Monitoring Medical PolicyNC Medicare 05/06/2019
Transtelephonic Monitoring Medical PolicyOH Medicare 05/06/2019
Tysabri Drug PolicyNC Medicare10/21/2019
Tysabri Drug PolicyOH Medicare10/21/2019
Velcade Drug PolicyNC Medicare01/15/2019
Vimizim Drug PolicyNC Medicare 10/21/2019
Vimizim Drug PolicyOH Medicare 10/21/2019
Xolair Drug PolicyKY Medicare07/15/2018
Xolair Drug PolicyNC Medicare10/21/2019
Xolair Drug PolicyOH Medicare10/21/2019
Yervoy Drug PolicyKY Medicare07/15/2018
Yervoy Drug PolicyOH Medicare07/15/2018
Scanning Computerized Ophthalmic Diagnostic Imaging Medical PolicyOH Medicare07/15/2019
Scanning Computerized Ophthalmic Diagnostic Imaging Medical PolicyNC Medicare07/15/2019
Panniculectomy, Abdominoplasty/ Lipectomy Medical PolicyPA Medicare08/17/2020
Vitamin D Deficiency Medical PolicyOH Medicare08/12/2019
Panniculectomy, Abdominoplasty/ Lipectomy Medical PolicyOH Medicare08/12/2019
Vitamin D Deficiency Medical PolicyNC Medicare08/12/2019
Panniculectomy, Abdominoplasty/ Lipectomy Medical PolicyNC Medicare08/12/2019
Observation Care (Hospital Outpatient) Medical PolicyPA Medicare10/19/2020
Negative Pressure Wound Therapy (NPWT) Pumps (L33821) Medical Policy PA Medicare 10/19/2020
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 PolicyPA Medicare12/21/2020
Noninvasive Vascular Studies Medical PolicyOH Medicare10/21/2019
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 PolicyPA Medicare07/19/2021
CPAP for Obstructive Sleep Apnea (OSA) Medical PolicyPA Medicare07/27/2020
Percutaneous Transluminal Angioplasty (PTA) (NCD 20.7) Medical PolicyPA Medicare07/19/2021
Non-Invasive Peripheral Venous Studies (L35451) Medical PolicyPA Medicare07/27/2020
Scanning Computerized Ophthalmic Diagnostic Imaging Medical PolicyPA Medicare07/27/2020
Acupuncture for Chronic Low Back Pain
(NCD 30.3.3)
Medical PolicyPA Medicare01/01/2021
Implantable Continuous Glucose Monitors (I-CGM) (L38617) Medical PolicyPA Medicare01/18/2021
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (L38495) Medical PolicyPA Medicare01/18/2021
Blood Glucose Testing (NCD 190.20) Medical PolicyPA Medicare02/15/2021
Oral Appliances for Obstructive Sleep Apnea (L33611) Medical PolicyPA Medicare02/15/2021
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (1.38385) Medical PolicyPA Medicare04/19/2021
Vitamin D Deficiency Screening Medical PolicyPA Medicare 06/21/2021

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.

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