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.
- DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- LAB.00011 Selected Protein Biomarker Algorithmic Assays
- LAB.00045 Selected Tests for the Evaluation and Management of Infertility
- LAB.00046 Testing for Biochemical Markers for Alzheimer’s Disease
- MED.00013 Parenteral Antibiotics for the Treatment of Lyme Disease
- MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- 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
- RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
- SURG.00010 Treatments for Urinary Incontinence
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
- 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.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis
- SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- SURG.00121 Transcatheter Heart Valve Procedures
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
- SURG.00155 Cryoneurolysis
- TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
- 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-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
- CG-DME-31 Powered Wheeled Mobility Devices
- CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
- CG-DME-36 Pediatric Gait Trainers
- CG-DME-42 Continuous Glucose Monitoring Devices and External Infusion Pumps
- CG-DME-44 Electric Tumor Treatment Field (TTF)
- CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory Failure
- CG-DME-50 Automated Insulin Delivery Systems
- CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing
- CG-LAB-32 Cancer Antigen 125 Testing
- CG-MED-26 Neonatal Levels of Care
- CG-MED-39 Bone Mineral Density Testing Measurement
- CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
- CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
- CG-SURG-01 Colonoscopy
- CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)
- CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver
- 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-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone