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 and Groin
- 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
- GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer
- GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- LAB.00011 Selected Protein Biomarker Algorithmic Assays
- LAB.00016 Fecal Analysis 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 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.00046 Testing for Biochemical Markers for Alzheimer’s Disease
- MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
- 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.00135 Gene Therapy for Hemophilia
- MED.00140 Gene Therapy for Beta Thalassemia
- 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.00037 Treatment of Varicose Veins (Lower Extremities)
- SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
- SURG.00097 Scoliosis Surgery
- SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
- SURG.00142 Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- SURG.00144 Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
- 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.00027 Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
- 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-39 Dynamic Low-Load Prolonged-Duration Stretch Devices
- CG-DME-42 Non-implantable Insulin Infusion and Blood Glucose Monitoring 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-GENE-13 Genetic Testing for Inherited Diseases
- CG-GENE-18 Genetic Testing for TP53 Mutations
- CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing
- CG-LAB-09 Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
- CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing
- CG-MED-08 Home Enteral Nutrition
- CG-MED-39 Bone Mineral Density Testing Measurement
- CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
- CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
- CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue
- CG-MED-83 Site of Care: Specialty Pharmaceuticals
- CG-MED-88 Preimplantation Embryo Biopsy and Genetic Testing
- 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-12 Penile Prosthesis Implantation
- CG-SURG-18 Septoplasty
- CG-SURG-31 Treatment of Keloids and Scar Revision
- CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy
- CG-SURG-59 Vena Cava Filters
- CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver
- CG-SURG-70 Gastric Electrical Stimulation
- CG-SURG-73 Balloon Sinus Ostial Dilation
- CG-SURG-78 Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
- CG-SURG-79 Implantable Infusion Pumps
- CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
- CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
- CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction
- CG-SURG-94 Keratoprosthesis
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention
- CG-SURG-96 Intraocular Telescope
- CG-SURG-97 Cardioverter Defibrillators
- CG-SURG-114 Ophthalmic use of Nd:YAG Laser for Posterior Capsulotomy