Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
 
   

Policy #
Policy Bulletin Title
MA07.055c
Allergy Immunotherapy
MA07.005c
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
MA07.026e
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
MA07.018b
Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters
MA07.027b
Autonomic Nervous System Testing
MA07.010a
Biofeedback Therapy
MA07.052
Bioimpedance for the Detection of Lymphedema
MA07.042
Complete Decongestive Therapy (CDT)
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MA07.046e
Corneal Pachymetry Using Ultrasound
MA07.041b
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
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MA07.013d
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
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MA07.050f
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA07.015a
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
MA07.012a
External Counterpulsation (ECP)
MA07.006a
Fecal Microbiota Transplantation (FMT)
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MA07.001a
Hyperbaric Oxygen Therapy
MA07.017c
Hyperthermic Intraperitoneal Chemotherapy for Select IntraAbdominal and Pelvic Malignancies
MA07.048a
Instrument-Based Vision Screening
MA07.051f
Intraoperative Neurophysiological Testing
MA07.025d
Intrauterine Systems (IUSs) (e.g., Mirena®, Skyla®, Liletta®, Kyleena®)
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MA07.016b
Intravenous Chelation Therapy
MA07.031a
Laboratory-Based Vestibular Function Testing
MA07.036c
Low-Level Laser Therapy
MA07.014
Magnetic Pelvic Floor Stimulation (MPFS)
MA07.039a
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
MA07.044b
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
MA07.024c
Medical and Surgical Treatment of Temporomandibular Joint Disorder
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MA07.033f
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
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MA07.038e
Neuropsychological Testing for Neurologically Based Conditions
MA07.053a
Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home
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MA07.047g
Pain Management of Peripheral Nerves by Injection
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MA07.021b
Partial Coherence Interferometry
MA07.003d
Photodynamic Therapy Using Verteporfin (Visudyne®)
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MA07.056d
Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
MA07.030b
Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
MA07.020a
Photography, including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy
MA07.008b
Platelet-Rich Plasma (PRPs) for Chronic Non-Healing Wounds and Stem-Cell Therapy for Orthopedic Applications
MA07.007g
Pulmonary Function Tests
MA07.029b
Refractive Lenses
MA07.019a
Reimbursement for the Administration of Immunizations
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MA07.009g
Routine Foot Care for Certain Medical Conditions
MA07.004e
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
MA07.058h
Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies
MA07.043a
Smell and Taste Dysfunction Testing
MA07.011a
Topical Oxygenation
MA07.040b
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
MA07.035c
Transcranial Magnetic Stimulation (TMS)
MA07.032
Tumor Treating Fields
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MA07.002c
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
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MA07.023e
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
MA07.022b
Wireless Capsule Endoscopy









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