Historical Medical Policies and Clinical UM Guidelines
Historical Medical Policies
Medical policies contained within this page are historical and not the most current versions. Current medical policy content may be accessed from the Medical Policies & Clinical UM Guidelines page. Implementation dates of the most current versions vary per state notification requirements.
- ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
- DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- DME.00047 Rehabilitative Devices with Remote Monitoring
- DME.00048 Virtual Reality-Assisted Therapy Systems
- LAB.00011 Selected Protein Biomarker Algorithmic Assays
- LAB.00016 Fecal Analysis Panels in the Diagnosis of Intestinal Disorders
- LAB.00019 Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
- LAB.00026 Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer
- LAB.00028 Blood-based Biomarker Tests for Multiple Sclerosis; Previously titled: Serum Biomarker Tests for Multiple Sclerosis
- LAB.00031 Advanced Lipoprotein Testing
- LAB.00039 Pooled Antibiotic Sensitivity Testing
- LAB.00046 Testing for Biochemical Markers for Alzheimer’s Disease
- MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease
- MED.00055 Wearable Cardioverter Defibrillators
- MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
- MED.000132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
- MED.00134 Non-invasive Heart Failure and Arrhythmia Management and Monitoring System
- MED.00135 Gene Therapy for Hemophilia
- MED.00140 Gene Therapy for Beta Thalassemia
- MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy
- MED.00144 Gene Therapy for Duchenne Muscular Dystrophy
- SURG.00010 Treatments for Urinary Incontinence
- SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
- SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
- SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- SURG.00097 Scoliosis Surgery
- SURG.00121 Transcatheter Heart Valve Procedures
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
- SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves
- SURG.00142 Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- TRANS.00023 Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
- TRANS.00024 Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
- TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
- TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
- TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products
- TRANS.00039 Portable Normothermic Organ Perfusion Systems
Historical Clinical UM Guidelines
Clinical UM guidelines contained within this page are historical and not the most current versions. Current clinical UM guideline content may be accessed from the Medical Policies & Clinical UM Guidelines page. Implementation dates of the most current versions vary per state notification requirements.
- CG-DME-06 Compression Devices for Lymphedema
- CG-DME-31 Powered Wheeled Mobility Devices
- CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance
- CG-DME-44 Electric Tumor Treatment Field (TTF)
- CG-DME-49 Standing Frames
- CG-LAB-32 Cancer Antigen 125 Testing
- CG-MED-39 Bone Mineral Density Testing Measurement
- CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
- CG-MED-68 Therapeutic Apheresis
- CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
- CG-MED-92 Foot Care Services
- CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
- CG-SURG-01 Colonoscopy
- CG-SURG-09 Temporomandibular Disorders
- CG-SURG-31 Treatment of Keloids and Scar Revision
- CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy
- CG-SURG-57 Diagnostic Nasal Endoscopy
- CG-SURG-59 Vena Cava Filters
- CG-SURG-78 Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
- CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
- CG-SURG-94 Keratoprosthesis
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention
- CG-SURG-114 Ophthalmic use of Nd:YAG Laser for Posterior Capsulotomy