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MPDocType
Title
MPPolicyNumber
MPNotificationIssuedDate
MPEffectiveDate
MPReissuedDate
MPArchiveNotifEffDate
MPSALogCreatedOn
MPPolicyChangeTypeslt
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New Policies
Eladocagene exuparvovec-tneq (Kebilidi™)
08.02.37
11/13/2024
5/5/2025
This is a New Policy.
New Policies
Imetelstat (Rytelo™)
08.02.30
5/19/2025
5/19/2025
This is a New Policy.
Updated Policies
Experimental/Investigational Services
12.01.01bp
4/1/2025
5/5/2025
Medical Coding
Updated Policies
Givosiran (Givlaari) and Panhematin (Hemin)
08.00.21a
5/19/2025
5/19/2025
Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
Updated Policies
Dostarlimab-gxly (Jemperli)
08.01.79f
5/19/2025
5/19/2025
Medical Necessity Criteria
Reissue Policies
Home Health Care Services
02.01.01g
1/6/2025
5/1/2025
5/1/2025
Reissue Policies
Hospice Care
02.02.01h
12/6/2021
5/14/2025
5/14/2025
Reissue Policies
Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie)
11.03.05e
1/1/2021
5/14/2025
5/14/2025
Reissue Policies
Denervation of the Spinal Nerves for Chronic Pain (Independence Administrators)
11.15.09r
12/2/2024
5/14/2025
5/14/2025
Reissue Policies
Artificial Intervertebral Cervical Disc Insertion (Independence Administrators)
11.14.19p
1/10/2021
5/14/2025
5/14/2025
Reissue Policies
Spinal Cord Ganglion and Dorsal Root Ganglion Stimulation (Independence Administrators)
11.15.01y
1/2/2024
5/14/2025
5/14/2025
Reissue Policies
Spinal Laminectomy (Independence Administrators)
11.14.28e
1/1/2022
5/14/2025
5/14/2025
Coding Update
Rapid Whole Exome Sequencing (rWES) and Rapid Whole Genome Sequencing (rWGS) for Diagnosis of Genetic Disorders
06.02.46a
1/1/2024
5/16/2025
Archived Policies
Complete Decongestive Therapy (CDT)
07.06.01b
5/5/2025 9:00 AM
6/9/2025
5/15/2025
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