It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again.
Advanced Search
Toggle navigation
Commercial
Home
Commercial Policies
Currently selected
Medicare Advantage Policies
MA PPO Host Policies
Contact Us
Commercial
Medical Policy
Policy Bulletins
Active Policy Notifications
Policy Types and Descriptions
Services Requiring Precertification
Coverage Guidelines
Select Cardiology Guidelines
Diagnostic Radiology Guidelines
Lab Management Guidelines
Musculoskeletal Guidelines
Radiation Therapy Guidelines
Sleep Disorder Management Guidelines
Specialty Medical Benefit Drugs
News & Announcements
Site Activity
Currently selected
Contact Us
MPDocType
Title
MPPolicyNumber
MPNotificationIssuedDate
MPEffectiveDate
MPReissuedDate
MPArchiveNotifEffDate
MPSALogCreatedOn
MPPolicyChangeTypeslt
MPRevisionDate
MPSiteActivityRemovedDate
Notifications
Therapeutic Transcranial Magnetic Stimulation (TMS)
07.03.22f
11/1/2024 1:00 PM
12/2/2024
11/1/2024
Medical Necessity Criteria
Notifications
Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring
11.00.06u
11/19/2024 11:00 AM
2/17/2025
11/19/2024
Medical Necessity Criteria
Notifications
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists, VEGF Biosimilars, and Combination VEGF/Angiopoietin-2 (Ang-2) Inhibitors
08.00.74x
10/8/2024 9:00 AM
1/1/2025
11/25/2024
Medical Necessity Criteria
11/25/2024
Updated Policies
Lower Limb Prostheses
05.00.59p
10/1/2024
11/4/2024
Medical Necessity Criteria
Updated Policies
Experimental/Investigational Services
12.01.01bn
10/1/2024
11/4/2024
Coverage and/or Reimbursement Position;Medical Coding
Updated Policies
Blinatumomab (Blincyto®)
08.01.21g
11/4/2024
11/4/2024
Medical Necessity Criteria;General Description, Guidelines, or Informational Update
Updated Policies
Routine/Non-routine Vaccines
08.01.04ae
11/18/2024
11/18/2024
Medical Necessity Criteria
Updated Policies
Margetuximab-cmkb (Margenza)
08.01.75d
6/19/2023
11/18/2024
Medical Necessity Criteria
Updated Policies
Teplizumab-mzwv (Tzield)
08.01.99b
11/18/2024
11/18/2024
Medical Necessity Criteria
Updated Policies
Musculoskeletal Services (Independence)
00.01.66n
11/17/2024
11/18/2024
Medical Necessity Criteria
Updated Policies
Carfilzomib (Kyprolis®)
08.01.05l
11/18/2024
11/18/2024
Medical Necessity Criteria
Updated Policies
Brentuximab Vedotin (Adcetris®)
08.01.13k
11/18/2024
11/18/2024
Medical Necessity Criteria
Updated Policies
Cemiplimab-rwlc (Libtayo®)
08.01.66d
11/18/2024
11/18/2024
Medical Necessity Criteria
Updated Policies
Criteria for Reimbursement of Emergency Room Services
00.10.03l
11/18/2024
11/18/2024
General Description, Guidelines, or Informational Update
Updated Policies
Eptinezumab-jjmr (VYEPTI™)
08.00.45e
11/18/2024
11/20/2024
Coverage and/or Reimbursement Position
Updated Policies
Gender-Affirming Interventions
11.09.02p
11/27/2024
11/27/2024
General Description, Guidelines, or Informational Update
Reissue Policies
Surgical Treatments of Athletic Pubalgia
11.14.26a
6/3/2015
11/13/2024
11/13/2024
Reissue Policies
Private Duty Nursing
02.01.02d
1/18/2021
11/13/2024
11/13/2024
Reissue Policies
Pneumatic Compression Therapy Devices
05.00.01o
7/31/2023
11/13/2024
11/13/2024
Reissue Policies
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy
06.02.01k
11/6/2023
11/13/2024
11/13/2024
Reissue Policies
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.29o
10/1/2023
11/13/2024
11/13/2024
Reissue Policies
Apos® biomechanical shoe system
05.00.84
1/1/2024
11/13/2024
11/13/2024
Reissue Policies
Deep Brain Stimulation (DBS)
11.15.20t
1/2/2024
11/13/2024
11/13/2024
Reissue Policies
Spinal Fusion (Independence Administrators)
11.14.27f
1/1/2022
11/13/2024
11/13/2024
Reissue Policies
Telemedicine Services
00.10.41m
7/1/2024
11/13/2024
11/13/2024
Reissue Policies
Neuropsychological Testing for Neurologically Based Conditions
07.03.08o
10/1/2023
10/16/2024
11/26/2024
11/26/2024
Coding Update
eviCore Lab Management (Independence)
06.02.52ah
10/1/2024
11/21/2024
Follow
javascript: SP.SOD.executeFunc('followingcommon.js', 'FollowDoc', function() { FollowDoc('{ListId}', {ItemId}); });
0x0
0x0
ContentType
0x01
1100
Compliance Details
javascript:if (typeof CalloutManager !== 'undefined' && Boolean(CalloutManager) && Boolean(CalloutManager.closeAll)) CalloutManager.closeAll(); commonShowModalDialog('{SiteUrl}'+ '/_layouts/15/itemexpiration.aspx' +'?ID={ItemId}&List={ListId}', 'center:1;dialogHeight:500px;dialogWidth:500px;resizable:yes;status:no;location:no;menubar:no;help:no', function GotoPageAfterClose(pageid){if(pageid == 'hold') {STSNavigate(unescape(decodeURI('{SiteUrl}'))+ '/_layouts/15/hold.aspx' +'?ID={ItemId}&List={ListId}'); return false;} if(pageid == 'audit') {STSNavigate(unescape(decodeURI('{SiteUrl}'))+ '/_layouts/15/Reporting.aspx' +'?Category=Auditing&backtype=item&ID={ItemId}&List={ListId}'); return false;} if(pageid == 'config') {STSNavigate(unescape(decodeURI('{SiteUrl}'))+ '/_layouts/15/expirationconfig.aspx' +'?ID={ItemId}&List={ListId}'); return false;}}, null);
0x0
0x1
ContentType
0x01
898
Document Set Version History
/_layouts/15/images/versions.gif?rev=40
javascript:SP.UI.ModalDialog.ShowPopupDialog('{SiteUrl}'+ '/_layouts/15/DocSetVersions.aspx' + '?List={ListId}&ID={ItemId}')
0x0
0x0
ContentType
0x0120D520
330
Send To other location
/_layouts/15/images/sendOtherLoc.gif?rev=40
javascript:GoToPage('{SiteUrl}' + '/_layouts/15/docsetsend.aspx' + '?List={ListId}&ID={ItemId}')
0x0
0x0
ContentType
0x0120D520
350
Decline
Accept and go to Medical Policies
|
Decline