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
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08.00.62i
Abatacept (Orencia®) for Injection for Intravenous Use
08.00.62i
Attachment A
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12.00.01f
Acupuncture (Independence)
12.00.01f
Attachment A
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12.00.01f
Acupuncture
12.00.01f
Attachment A
12.04.04
Acute Care Facility Inpatient Transfers
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08.01.11d
Ado-Trastuzumab Emtansine (Kadcyla®)
08.01.11d
Attachment A
08.00.69b
Agalsidase beta (Fabrazyme®)
12.04.03c
Air Ambulance Services
08.01.22c
Alemtuzumab (Lemtrada®)
08.00.72h
Alglucosidase alfa (e.g., Lumizyme®)
07.00.21i
Allergy Immunotherapy
06.02.29d
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
06.02.29d
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)
08.00.91c
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
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00.01.52g
Always Bundled Procedure Codes
00.01.52g
Attachment A
07.02.09e
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21c
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
01.00.02b
Anesthesia Services for a Cancelled or Discontinued Procedure
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05.00.39o
Ankle-Foot/Knee-Ankle-Foot Orthoses
05.00.39o
Attachment A
06.03.04n
Apheresis Therapy
11.08.05g
Application and Removal of Tattoos
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08.01.41c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
08.01.41c
Attachment A
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11.05.16g
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
11.05.16g
Attachment A
11.14.19l
Artificial Intervertebral Disc Insertion
08.01.35a
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
06.02.27l
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (AmeriHealth Administrators)
06.02.27l
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)
07.10.06f
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
06.03.05e
Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
11.14.06i
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
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05.00.29k
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.29k
Attachment A
05.00.29k
Attachment B
07.03.23b
Autonomic Nervous System Testing
11.16.06h
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
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11.03.02r
Bariatric Surgery
11.03.02r
Attachment A
11.03.02r
Attachment B
11.03.02r
Attachment C
08.01.03c
Belatacept (Nulojix®)
08.00.99b
Belimumab (Benlysta®) for Intravenous Use
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08.00.66k
Bevacizumab (Avastin®) and related biosimilars
08.00.66k
Attachment A
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00.10.39j
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
00.10.39j
Attachment A
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00.10.38
Billing Requirements for Multiple Births for Professional Providers
00.10.38
Attachment A
00.10.38
Attachment B
00.10.38
Attachment C
00.10.38
Attachment D
07.00.01h
Biofeedback Therapy
07.06.03b
Bioimpedance for the Detection of Lymphedema
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11.05.02i
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
11.05.02i
Attachment A
08.01.21c
Blinatumomab (Blincyto®)
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11.01.06d
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
11.01.06d
Attachment A
09.00.04i
Bone Mineral Density (BMD) Testing
08.00.73l
Bortezomib (Bortezomib for Injection, Velcade®)
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08.00.26u
Botulinum Toxin Agents
08.00.26u
Attachment A
09.00.10y
Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (AmeriHealth Administrators)
09.00.10y
Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (Independence Administrators)
05.00.76b
Breast Pumps
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08.01.13c
Brentuximab Vedotin (Adcetris®)
08.01.13c
Attachment A
11.16.07b
Bronchial Thermoplasty
08.01.49a
Burosumab-twza (Crysvita®)
08.00.96d
Cabazitaxel (Jevtana®)
08.01.51
Canakinumab (Ilaris®)
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10.01.01n
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
10.01.01n
Attachment A
00.01.59e
Care Management and Care Planning Services
08.01.05e
Carfilzomib (Kyprolis™)
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00.10.15c
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
00.10.15c
Attachment A
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11.01.07d
Cataract Surgery
11.01.07d
Attachment A
11.02.06l
Catheter Ablation of Cardiac Arrhythmias
08.01.39c
Cerliponase alfa (Brineura®)
05.00.61f
Cervical Traction Devices for In-home Use
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08.00.67k
Cetuximab (Erbitux®)
08.00.67k
Attachment A
08.00.67k
Attachment B
11.08.08g
Chemical Peels
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08.01.43d
Chimeric Antigen Receptor (CAR) Therapy
08.01.43d
Attachment A
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10.02.02i
Chiropractic Spinal and Extraspinal Manipulation Therapy
10.02.02i
Attachment A
08.00.92y
Coagulation Factors
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06.02.54
Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
06.02.54
Attachment A
11.01.02n
Cochlear Implant
11.03.12q
Colorectal Cancer Screening
12.00.03f
Complementary and Integrative Health Services
07.06.01b
Complete Decongestive Therapy (CDT)
11.14.30
Composite Tissue Allotransplantation of the Hand(s) and Face
05.00.37f
Compression Garments
09.00.42c
Computer-Aided Detection (CAD) System for Use with Chest Radiographs
11.14.17d
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures
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07.13.11i
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
07.13.11i
Attachment A
01.00.09c
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
05.00.08e
Continuous Passive Motion (CPM) Devices in the Home Setting
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07.13.07j
Corneal Pachymetry Using Ultrasound
07.13.07j
Attachment A
12.01.03
Cosmetic Procedures
08.01.08d
Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
05.00.25h
Cranial Remolding Orthoses (Helmets)
00.10.03i
Criteria for Reimbursement of Emergency Room Services
11.11.03d
Cryosurgical Ablation of the Prostate Gland
08.01.29d
Daratumumab (Darzalex™)
10.00.02b
Day Rehabilitation
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11.08.17h
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.17h
Attachment A
11.08.17h
Attachment B
11.08.17h
Attachment C
11.08.17h
Attachment D
11.08.17h
Attachment E
11.15.20o
Deep Brain Stimulation (DBS)
11.15.09l
Denervation of the Spinal Nerves for Chronic Pain
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08.00.94k
Denosumab (Prolia®, Xgeva®)
08.00.94k
Attachment A
04.00.03a
Dental Extractions Prior to Cardiac Surgery, Radiation Therapy, or Transplant Surgery
08.01.24
Deoxycholic Acid (Kybella™)
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00.03.02y
Diagnostic Radiology Services Included in Capitation
00.03.02y
Attachment A
00.03.02y
Attachment B
00.09.01e
Direct Access Obstetrics/Gynecology (OB/GYN)
08.00.49d
Dofetilide (Tikosyn®) Use in the Inpatient Setting
07.05.07c
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
08.01.37
Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Probuphine Implant, Vivitrol Injection)
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05.00.21t
Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21t
Attachment A1
05.00.21t
Attachment A2
05.00.21t
Attachment B
05.00.48j
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
09.00.11c
Echocardiography Contrast Agents
08.00.84d
Eculizumab (Soliris®)
08.01.42a
Edaravone (Radicava™)
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11.06.02i
Elective Abortion
11.06.02i
Attachment A
05.00.09h
Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
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07.07.07f
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
07.07.07f
Attachment A
03.02.12c
Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)
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07.03.09o
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09o
Attachment A
07.03.09o
Attachment B
07.03.09o
Attachment C
07.03.09o
Attachment D
07.03.09o
Attachment E
07.03.09o
Attachment F
07.03.09o
Attachment G
07.03.09o
Attachment H
07.03.09o
Attachment I
07.03.09o
Attachment J
07.03.09o
Attachment K
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07.03.21j
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.21j
Attachment A
09.00.02e
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
08.01.54
Emapalumab-lzsg (Gamifant®)
11.06.05f
Endometrial Ablation
11.02.10m
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
11.02.17f
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
08.00.51j
Enzyme Replacement for the Treatment of Gaucher's Disease
08.01.26a
Enzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., pegademase bovine [Adagen®], elapegademase-lvlr [Revcovi™])
08.00.70e
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
11.15.23g
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
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05.00.05k
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.05k
Attachment A
05.00.05k
Attachment B
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08.00.98e
Eribulin Mesylate (Halaven®)
08.00.98e
Attachment A
08.00.75m
Erythropoiesis-Stimulating Agents (ESAs)
07.02.22
Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
07.03.07r
Evaluation and Management of Autism Spectrum Disorders (ASD)
07.03.15d
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
11.11.01i
Evaluation and Treatment of Erectile Dysfunction (ED)
03.02.13f
Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG)
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06.02.52l
eviCore Lab Management Program (AmeriHealth)
06.02.52l
Attachment A
06.02.52l
Attachment B
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06.02.52l
eviCore Lab Management Program (Independence)
06.02.52l
Attachment A
06.02.52l
Attachment B
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12.01.01ar
Experimental/Investigational Services
12.01.01ar
Attachment A
12.01.01ar
Attachment B
12.01.01ar
Attachment C
07.02.05j
External Counterpulsation (ECP)
11.14.13g
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
04.00.05d
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth

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