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.
- ADMIN.00001 Medical Policy Formation
- ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
- DME.00009 Vacuum Assisted Wound Therapy in the Outpatient Setting
- DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- DME.00037 Cooling Devices and Combined Cooling/Heating Devices
- GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
- GENE.00016 Gene Expression Profiling for Colorectal Cancer
- GENE.00023 Gene Expression Profiling of Melanomas
- GENE.00025 Proteogenomic Testing for the Evaluation of Malignancies
- GENE.00037 Genetic Testing for Macular Degeneration
- GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD)
- GENE.00046 Prothrombin G20210A (Factor II) Mutation Testing
- GENE.00049 Circulating Tumor DNA Panel Testing for Cancer (Liquid Biopsy)
- GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- GENE.00055 Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
- LAB.00011 Analysis of Proteomic Patterns
- LAB.00024 Immune Cell Function Assay
- LAB.00026 Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
- LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests
- LAB.00031 Advanced Lipoprotein Testing
- LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
- LAB.00034 Serological Antibody Testing For Helicobacter Pylori
- LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
- MED.00002 Selected Sleep Testing Services
- MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
- MED.00065 Hepatic Activation Therapy
- MED.00091 Rhinophototherapy
- MED.00092 Automated Nerve Conduction Testing
- MED.00097 Neural Therapy
- MED.00099 Electromagnetic Navigational Bronchoscopy
- MED.00102 Ultrafiltration in Decompensated Heart Failure
- MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, Soft Tissue Grafting, and Regenerative Therapy
- MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
- MED.00116 Near-Infrared Spectroscopy Brain Screening for Hematoma Detection
- MED.00120 Voretigene neparvovec-rzyl (Luxturna®)
- MED.00121 Implantable Interstitial Glucose Sensors
- MED.00122 Wilderness Programs
- MED.00128 Insulin Potentiation Therapy
- MED.00129 Gene Therapy for Spinal Muscular Atrophy
- MED.00130 Surface Electromyography Devices for Seizure Monitoring
- MED.00131 Electronic Home Visual Field Monitoring
- OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis
- OR-PR.00004 Partial-Hand Myoelectric Prosthesis
- RAD.00036 MRI of the Breast
- RAD.00053 Cervical and Thoracic Discography
- RAD.00065 Radiostereometric Analysis (RSA)
- REHAB.00003 Hippotherapy
- SURG.00010 Treatments for Urinary Incontinence
- SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00019 Transmyocardial Revascularization
- SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
- SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
- SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations
- SURG.00037 Treatment of Varicose Veins (Lower Extremities)
- SURG.00044 Breast Ductal Examination and Fluid Cytology Analysis
- SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions
- SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
- SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- SURG.00062 Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
- SURG.00073 Epiduroscopy
- SURG.00077 Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
- SURG.00079 Nasal Valve Suspension
- SURG.00096 Surgical and Ablative Treatments for Chronic Headaches
- SURG.00097 Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
- SURG.00098 Mechanical Embolectomy for Treatment of Acute Stroke
- SURG.00099 Convection Enhanced Delivery of Therapeutic Agents to the Brain
- SURG.00100 Cryoablation for Plantar Fasciitis and Plantar Fibroma
- SURG.00102 Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
- SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
- SURG.00121 Transcatheter Heart Valve Procedures
- SURG.00123 Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
- SURG.00130 Annulus Closure After Discectomy
- SURG.00138 Laser Treatment for Onychomycosis
- SURG.00142 Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- SURG.00143 Perirectal Spacers for Use During Prostate Radiotherapy
- SURG.00146 Extracorporeal Carbon Dioxide Removal
- SURG.00154 Microsurgical Procedures for the Treatment of Lymphedema
- SURG.00155 Cryoneurolysis for Treatment of Peripheral Nerve Pain
- SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
- THER-RAD.00008 Neutron Beam Radiotherapy
- TRANS.00008 Liver Transplantation
- TRANS.00009 Lung and Lobar Transplantation
- TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
- 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.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
- TRANS.00026 Heart/Lung Transplantation
- TRANS.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
- TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
- TRANS.00030 Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
- TRANS.00033 Heart Transplantation
- TRANS.00034 Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
- TRANS.00035 Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases
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-ANC-03 Acupuncture
- CG-ANC-04 Ambulance Services: Air and Water
- CG-ANC-05 Ambulance Services: Ground; Emergent
- CG-ANC-07 Inpatient Interfacility Transfers
- CG-BEH-01 Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome
- CG-BEH-14 Intensive In-home Behavioral Health Services
- CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
- CG-DME-06 Pneumatic Compression Devices for Lymphedema
- CG-DME-07 Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output
- CG-DME-13 Lower Limb Prosthesis
- CG-DME-21 External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings
- CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
- CG-DME-30 Prothrombin Time Self-Monitoring Devices
- CG-DME-31 Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
- CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
- CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
- CG-DME-37 Air Conduction Hearing Aids
- CG-DME-40 Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
- CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance
- CG-DME-44 Electric Tumor Treatment Field (TTF)
- CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities
- CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory Failure
- CG-DME-48 Vacuum Assisted Wound Therapy in the Outpatient Setting
- CG-GENE-02 Analysis of RAS Status
- CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules
- CG-GENE-13 Genetic Testing for Inherited Diseases
- CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
- CG-GENE-19 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
- CG-LAB-03 Tropism Testing for HIV Management
- CG-LAB-09 Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
- CG-LAB-13 Skin Nerve Fiber Density Testing
- CG-LAB-14 Respiratory Viral Panel Testing in the Outpatient Setting
- CG-LAB-15 Red Blood Cell Folic Acid Testing
- CG-MED-19 Custodial Care
- CG-MED-21 Anesthesia Services and Moderate (“Conscious”) Sedation
- CG-MED-23 Home Health
- CG-MED-28 Iontophoresis for Medical Indications
- CG-MED-38 Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
- CG-MED-42 Maternity Ultrasound in the Outpatient Setting
- CG-MED-53 Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing
- CG-MED-54 Strapping
- CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)
- CG-MED-68 Therapeutic Apheresis
- CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
- CG-MED-71 Chronic Wound Care in the Home or Outpatient Setting
- CG-MED-72 Hyperthermia for Cancer Therapy
- CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
- CG-MED-77 SPECT/CT Fusion Imaging
- CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures
- CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
- CG-MED-81 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications
- CG-MED-85 Posterior Segment Optical Coherence Tomography
- CG-MED-86 Enhanced External Counterpulsation in the Outpatient Setting
- CG-OR-PR-03 Custom-made Knee Braces
- CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics)
- CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
- CG-REHAB-02 Outpatient Cardiac Rehabilitation
- CG-REHAB-03 Pulmonary Rehabilitation
- CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
- CG-SURG-09 Temporomandibular Disorders
- CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures
- CG-SURG-27 Sex Reassignment Surgery
- CG-SURG-29 Lumbar Discography
- CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy
- CG-SURG-36 Adenoidectomy
- CG-SURG-41 Surgical Strabismus Correction
- CG-SURG-59 Vena Cava Filters
- CG-SURG-70 Gastric Electrical Stimulation
- CG-SURG-72 Endothelial Keratoplasty
- CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
- CG-SURG-77 Refractive Surgery
- CG-SURG-78 Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
- CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids
- CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic
- CG-SURG-91 Minimally Invasive Ablative Procedures for Epilepsy
- CG-SURG-92 Paraesophageal Hernia Repair
- CG-SURG-94 Keratoprosthesis
- CG-SURG-96 Intraocular Telescope
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary)