Medical, Behavioral, and Administrative Policy A-Z Index (Commercial and Medicare Advantage**see below for Medicare Advantage Coverage Policy Development and Application)

Document Title Document Type Document Size Effective Date
A
Ablative Treatment for Malignant Breast Tumor - (0540) PDF 256kB 03/15/2023
Abortion - (A006) PDF 193kB 11/15/2022
Acupuncture - (CPG024) PDF 568kB 04/15/2023
Airway Clearance Devices in the Ambulatory Setting - (0069) PDF 311kB 11/12/2023
Allergy Testing and Non-Pharmacologic Treatment - (0070) PDF 371kB 12/03/2023
Ambulatory External and Implantable Electrocardiographic Monitoring - (0547) PDF 611kB 10/15/2023
American Society of Addiction Medicine (ASAM) Guideline Online Resource
Anesthesia and Facility Services for Dental Treatment - (0415) PDF 276kB 08/15/2023
Anesthesia Services for Interventional Pain Management Procedures in an Adult - (0551) PDF 436kB 02/15/2024
Angioplasty (Extracranial, Intracranial) and Intracranial Aneurysm Repair - (0545) PDF 363kB 11/15/2023
Atherosclerotic Cardiovascular Disease Risk Assessment: Emerging Laboratory Evaluations - (0137) PDF 641kB 08/15/2023
Athletic Pubalgia Surgery - (0522) PDF 259kB 07/15/2023
Attention-Deficit/Hyperactivity Disorder (ADHD): Assessment and Treatment - (0231) PDF 383kB 01/15/2024
Authorized Generics - (A008) PDF 183kB 01/01/2024
Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment - (0447) PDF 502kB 12/03/2023
Autologous Platelet-Derived Growth Factors (Platelet-Rich Plasma [PRP]) - (0507) PDF 410kB 10/15/2023
Autonomic Nerve Function Testing - (0506) PDF 293kB 02/15/2024
Axial/Spinal Decompression Therapy/Mechanical Traction (Provided in a Clinic Setting) - (CPG275)

PDF 415kB 04/15/2023
B
Balloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation - (0480) PDF 369kB 04/15/2023
Bariatric Surgery and Procedures - (0051) PDF 1299kB 07/15/2023
Behavioral Health Coaching and Peer Support Services - (A015) PDF 188kB 04/15/2023
Benign Prostatic Hyperplasia (BPH) Surgical Treatments - (0159) PDF 510kB 12/15/2023
Biofeedback - (CPG294) PDF 635kB 11/15/2023
Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift - (0045) PDF 301kB 04/15/2023
Bone Graft Substitutes - (0118) PDF 265kB 02/15/2024
Bone Growth Stimulators: Electrical (Invasive, Noninvasive), Ultrasound - (0084) PDF 302kB 05/15/2023
Bone Mineral Density Measurement - (0300) PDF 373kB 04/15/2023
Brachytherapy Online Resource
Breast Implant Removal - (0048) PDF 291kB 01/15/2024
Breast Reconstruction Following Mastectomy or Lumpectomy - (0178) PDF 604kB 03/15/2023
Breast Reduction - (0152)

PDF 260kB 08/15/2023
C
Capsule Endoscopy Online Resource
Cardiac Catheterization Online Resource
Cardiac Electrophysiological (EP) Studies - (0532) PDF 317kB 10/15/2023
Cardiac Nuclear Imaging Online Resource
Cardiac Rehabilitation (Phase II Outpatient) - (0073) PDF 441kB 05/15/2023
Cardiac Resynchronization Therapy (CRT) and Advanced Cardiac Pacing Technologies - (0174) PDF 684kB 01/15/2024
Cardiac Stress Echocardiography Online Resource
Carotid Intima-Media Thickness Measurement - (0475) PDF 295kB 05/15/2023
Category III Current Procedural Terminology (CPT®) Codes - (0558) PDF 156kB 08/15/2023
Cell-Based Therapy for Cardiac and Peripheral Arterial Disease - (0287) PDF 444kB 04/15/2023
Cervical Cancer Screening Visualization Technologies - (0127) PDF 255kB 09/15/2023
Cervical Fusion - (0527) PDF 353kB 06/15/2023
Chiropractic Care - (CPG278) PDF 504kB 12/03/2023
Clinical Trials – (A003) PDF 197kB 12/15/2023
Cochlear and Auditory Brainstem Implants - (0190) PDF 539kB 11/15/2023
Cognitive Rehabilitation - (CPG270) PDF 518kB 12/03/2023
Colorectal Cancer Screening and Surveillance - (0148) PDF 527kB 11/15/2023
Comparative Genomic Hybridization (CGH)/Chromosomal Microarray Analysis (CMA) for Selected Hereditary Conditions - (0493) PDF 296kB 06/15/2023
Complementary and Alternative Medicine - (EN0086) PDF 693kB 02/15/2024
Complex Lymphedema Therapy (Complete Decongestive Therapy) - (CPG157) PDF 484kB 05/15/2023
Compression Devices - (0354) PDF 369kB 12/03/2023
Computed Tomography (CT) Online Resource
Computed Tomography Angiography (CTA) Online Resource
Computed Tomography for Lung Cancer Screening Online Resource
Continuity of Care Service Requests - (UM-41) PDF 4440kB 01/08/2024
Continuous Passive Motion (CPM) Devices - (0198) PDF 247kB 08/01/2023
Corneal Remodeling for Refractive Errors - (0141) PDF 412kB 10/15/2023
COVID-19: In Vitro Diagnostic Testing - (0557) PDF 389kB 12/03/2023
Custodial and Non-Skilled Services - (A012)

PDF 196kB 10/15/2023
D
Deep Brain, Motor Cortex and Responsive Cortical Stimulation - (0184) PDF 551kB 12/15/2023
Diabetes Equipment and Supplies - (0106) PDF 669kB 02/15/2024
Diagnostic Cardiac Catheterization Online Resource
Diagnostic Nasal/Sinus Endoscopy, Functional Endoscopic Sinus Surgery (FESS) and Turbinectomy - (0554) PDF 562kB 10/15/2023
Diaphragmatic/Phrenic Nerve Stimulation - (0391) PDF 360kB 09/15/2023
Discography - (0393) PDF 304kB 11/15/2023
Distraction Osteogenesis (DO) for Craniofacial Deformities - (0407) PDF 225kB 09/15/2023
Donor Lymphocyte Infusion and Hematopoietic Progenitor Cell (HPC) Boost - (0261) PDF 266kB 05/15/2023
Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery - (0481) PDF 408kB 04/15/2023
Drug Testing - (0513) PDF 254kB 01/15/2024
Duplex Scan to Evaluate for Carotid Artery Stenosis - (0542)

PDF 384kB 10/15/2023
E
Electrical Stimulation Therapy and Devices in a Home Setting - (0160) PDF 870kB 12/03/2023
Electric Stimulation for Pain, Swelling and Function in a Clinic Setting - (CPG272) PDF 702kB 11/15/2023
Electrodiagnostic Testing (EMG/NCV) - (CPG129) PDF 974kB 11/12/2023
Electroencephalography - (0521) PDF 251kB 01/15/2024
Emergency Room Services - (A005) PDF 132kB 10/01/2023
Endometrial Ablation - (0013) PDF 265kB 02/15/2024
Epidural Adhesiolysis - (CMM 207) Online Resource
Epidural Steroid Injections - (CMM 200) Online Resource
Esophagogastroduodenoscopy (EGD) Online Resource
Exhaled Nitric Oxide in the Management of Respiratory Disorders - (0439) PDF 410kB 12/15/2023
External Counterpulsation - (0058) PDF 300kB 05/15/2023
Extracorporeal Photopheresis - (0320) PDF 212kB 08/15/2023
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds - (0004)

PDF 550kB 11/15/2023
F
Facet Joint Injections / Medial Branch Blocks - (CMM 201) Online Resource
Fetal Surgery - (0175) PDF 257kB 08/15/2023
Flow Cytometry - (0538)

PDF 312kB 10/15/2023
G
Gait Analysis - (0315) PDF 224kB 04/15/2023
Gastric Pacing/Gastric Electrical Stimulation (GES) - (0103) PDF 294kB 11/15/2023
Gastrointestinal Endoscopic Procedure Esophagogastroduodenoscopy (EGD) Online Resource
Gender Dysphoria Treatment - (0266) PDF 362kB 01/15/2024
Gender Dysphoria Treatment - State Guidelines PDF 184kB 01/01/2024
Genetic Testing for Hereditary and Multifactorial Conditions - (0052) PDF 648kB 01/15/2024
Genetic Testing for Hereditary Cancer Susceptibility Syndromes - (0518) PDF 344kB 08/15/2023
Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias - (0517) PDF 319kB 11/15/2022
Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514) PDF 828kB 12/03/2023
Genetic Testing Recommendation Form Online Resource
Glaucoma Surgical Procedures - (0035) PDF 562kB 06/15/2023
Gynecomastia Surgery - (0195)

PDF 191kB 11/15/2023
H
Headache, Occipital, and/or Trigeminal Neuralgia Treatment - (0063) PDF 470kB 01/15/2024
Head and Neck Ultrasound - (0549) PDF 363kB 10/15/2023
Hearing Aids - (0093) PDF 486kB 05/15/2023
Heart, Lung, and Heart-Lung Transplantation - (0129) PDF 318kB 09/15/2023
Helicobacter Pylori Serology Testing –(0308) PDF 212kB 05/15/2023
High Intensity Focused Ultrasound (HIFU) - (0274) PDF 474kB 01/15/2024
Hip Replacement/Arthroplasty - (CMM 313) Online Resource
Hip Surgery - Arthroscopic and Open Procedures - (CMM 314) Online Resource
Home Traction Devices - Cervical and Lumbar - (CPG265) PDF 361kB 04/15/2023
Home Ventilators - (0546) PDF 304kB 06/15/2023
Hospice Care - (0462) PDF 260kB 02/15/2024
Hospital Beds and Pressure Reducing Support Surfaces - (0042) PDF 352kB 11/12/2023
Hyperbaric and Topical Oxygen Therapies - (0053) PDF 483kB 05/15/2023
Hyperthermia

Online Resource
I
Image-Guided Radiation Therapy (IGRT) Online Resource
Implantable Cardioverter Defibrillator (ICD) - (0181) PDF 562kB 10/15/2023
Implantable Intrathecal Drug Delivery Systems - (CMM 210) Online Resource
Infertility Services - (0089) PDF 603kB 06/15/2023
Inflammatory Bowel Disease - Testing for the Diagnosis and Management - (0121) PDF 621kB 03/15/2023
Inhaled Nitric Oxide (INO) - (0453) PDF 523kB 06/15/2023
Injectable Fillers - (0511) PDF 294kB 05/15/2023
Intensive Behavioral Interventions - (EN0499) PDF 338kB 12/15/2023
Interspinous Process Spacer Devices - (0448) PDF 346kB 04/15/2023
Intervertebral Disc (IVD) Prostheses - (0104) PDF 656kB 01/15/2024
Intestinal and Multivisceral Transplantation - (0288) PDF 249kB 12/15/2023
Intraocular Lens Implant - (0125) PDF 263kB 11/12/2023
Intraoperative Monitoring - (0509)

PDF 633kB 10/15/2023
K
Kidney Transplantation, Pancreas-Kidney Transplantation, and Pancreas Transplantation Alone - (0146) PDF 286kB 10/15/2023
Knee Replacement/Arthroplasty - (CMM 311) Online Resource
Knee Surgery: Arthroscopic and Open Procedures - (CMM 312)

Online Resource
L
Laboratory Testing for Transplantation Rejection - (0465) PDF 374kB 12/15/2023
Lack of Information (LOI) Pre-Service - (UM-49) PDF 2350kB 01/08/2024
Lack of Information (LOI) Retrospective Review - (UM-47) PDF 1960kB 01/08/2024
Liver and Liver-Kidney Transplantation - (0355) PDF 231kB 04/15/2023
Low-Level Laser and High-Power Laser Therapy - (CPG030) PDF 634kB 03/15/2023
Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, including Sacroiliac Fusion - (0303) PDF 709kB 01/15/2024
Lyme Disease Treatment - Antibiotic Treatment - (0400) PDF 536kB 07/15/2023
Lymphedema and Lipedema Surgical Treatments - (0531)

PDF 497kB 10/15/2023
M
Magnetic Resonance Angiography (MRA) Online Resource
Magnetic Resonance Imaging (MRI) Online Resource
Magnetic Resonance Imaging (MRI), Breast Online Resource
Magnetic Resonance Imaging (MRI), Cardiac Online Resource
Magnetic Resonance Spectroscopy (MRS) Online Resource
Male Sexual Dysfunction Treatment: Non-pharmacologic - (0403) PDF 504kB 08/15/2023
Mammary Ductoscopy, Aspiration and Lavage - (0057) PDF 315kB 01/15/2024
Manipulation Under Anesthesia - (0276) PDF 259kB 10/15/2023
Metatarsophalangeal Joint Replacement - (0446) PDF 305kB 09/15/2023
Midwife, Home Birth and Non-Clinical Maternal Services - (A002) PDF 222kB 02/15/2023
Minimally Invasive Anti-Reflux Procedures and Peroral Endoscopic Myotomy (POEM) Procedures - (0019) PDF 767kB 10/15/2023
Minimally Invasive Spine Surgery Procedures and Trigger Point Injections - (0139) PDF 709kB 12/03/2023
Miscellaneous Musculoskeletal Procedures - (0515) PDF 611kB 11/12/2023
Molecular and Proteomic Diagnostic Testing for Hematology and Oncology Indications - (0520)

PDF 814kB 12/03/2023
N
Negative Pressure Wound Therapy/Vacuum Assisted Closure (VAC) for Nonhealing Wounds - (0064) PDF 404kB 05/15/2023
Network Adequacy Provision (NAP) - (UM-20) PDF 544kB 12/06/2023
Neuropsychological Testing - (EN0258) PDF 500kB 11/12/2023
Neutron Beam Radiation Therapy for Cancer Treatment Online Resource
Non-Participating Laboratory Services - (A001) PDF 170kB 01/15/2023
Nonpharmacological Treatments for Atrial Fibrillation - (0469) PDF 714kB 12/15/2023
Nucleic Acid Pathogen Testing - (0530)

PDF 667kB 12/03/2023
O
Occupational Therapy - (CPG155) PDF 566kB 12/03/2023
Omnibus Codes - (0504) PDF 1301kB 12/03/2023
Oncology Imaging Amendment to Cigna-eviCore General Oncology Imaging Guideline - (DV002) PDF 163kB 10/01/2023
Oncology Imaging Guidelines (Adult and Pediatric) Online Resource
Oral Appliances for the Treatment of Obstructive Sleep Apnea - (A016) PDf 208kB 01/15/2024
Oral Cancer Screening Systems - (0372) PDF 287kB 12/03/2023
Orthognathic Surgery - (0209) PDF 269kB 10/15/2023
Orthotic Devices and Shoes - (0543) PDF 818kB 12/03/2023
Otoplasty and External Ear Reconstruction - (0335)

PDF 249kB 04/15/2023
P
Pacemaker Online Resource
Pancreatic Islet Cell Transplantation - (0107) PDF 248kB 09/15/2023
Panniculectomy and Abdominoplasty - (0027) PDF 224kB 03/15/2023
Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations - (CPG111) PDF 404kB 07/15/2023
Pediatric Intensive Feeding Programs - (0422) PDF 232kB 12/15/2023
Pelvic Denervation Procedures - (0368) PDF 242kB 06/15/2023
Percutaneous Revascularization of the Lower Extermities in Adults - (0537) PDF 409kB 02/15/2024
Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty - (0040) PDF 442kB 08/15/2023
Peripheral Nerve Destruction for Pain Conditions - (0525) PDF 621kB 02/15/2024
Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation - (0539) PDF 338kB 04/15/2023
Pharmacogenetic Testing for Non-Cancer Indications - (0500) PDF 395kB 02/15/2024
Phototherapy, Photochemotherapy, Excimer Laser, Dermabrasion and Chemical Peels for Dermatologic Conditions - (0505) PDF 520kB 12/03/2023
Physical Performance Test or Measurement - (CPG295) PDF 325kB 11/15/2023
Physical Therapy - (CPG135) PDF 593kB 12/03/2023
Plantar Fasciitis Treatments - (0097) PDF 506kB 02/15/2024
Plasma Brain Natriuretic Peptide in the Outpatient Setting - (0028) PDF 322kB 05/15/2023
Plasmapheresis - (0153) PDF 473kB 06/15/2023
Positron Emission Tomography (PET) Online Resource
Preventive Care Services - (A004) PDF 589kB 01/15/2024
Prolotherapy - (CMM 204) Online Resource
Prosthetic Devices - (0536) PDF 440kB 01/15/2024
Proton Beam Therapy

Online Resource
R
Radiation Therapy for Cancers Online Resource
Radiofrequency Joint Ablations / Denervation - (CMM 208) Online Resource
Radioimmunotherapy with Zevalin Online Resource
Recurrent Pregnancy Loss: Diagnosis and Treatment - (0284) PDF 386kB 02/15/2023
Redundant Skin Surgery - (0470) PDF 219kB 06/15/2023
Regional Sympathetic Blocks - (CMM 209) Online Resource
Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) - (0563) PDF 295kB 12/03/2023
Rhinoplasty, Vestibular Stenosis Repair and Septoplasty - (0119) PDF 402kB 11/12/2023
Rosacea Procedures - (0482)

PDF 233kB 06/15/2023
S
Sacral Nerve and Tibial Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation - (0404) PDF 393kB 10/15/2023
Sacroiliac Joint Procedures - (CMM 203) Online Resource
Scar Revision - (0328) PDF 367kB 12/03/2023
Scrotal Ultrasound - (0548) PDF 295kB 10/15/2023
Seat Lift Mechanism, Patient Lifts and Standing Devices - (0343) PDF 247kB 05/15/2023
Selective Internal Radiation Therapy (SIRT) Online Resource
Sensory and Auditory Integration Therapy - Facilitated Communication - (CPG149) PDF 427kB 06/15/2023
Shoulder Arthroplasty / Replacement / Resurfacing / Revision / Arthrodesis - (CMM 318) Online Resource
Shoulder Surgery - Arthroscopic and Open Procedures - (CMM 315) Online Resource
Site of Care: High-tech Radiology - (0550) PDF 226kB 03/15/2023
Site of Care: Outpatient Hospital for Select Musculoskeletal Procedures - (0553) PDF 306kB 03/15/2023
Skin Cancer Surveillance Technologies - (0240) PDF 323kB 10/15/2023
Sleep Management Online Resource
Speech Generating Devices - (0049) PDF 248kB 03/15/2023
Speech Therapy - (0177) PDF 447kB 02/15/2023
Spinal Cord and Dorsal Root Ganglion Stimulation - (CMM 211) Online Resource
Spinal Ultrasound - (CPG038) PDF 279kB 10/15/2023
Staff-Assisted Home Hemodialysis - (0229) PDF 187kB 11/15/2023
Stem Cell Therapy for Orthopaedic Applications - (0552) PDF 344kB 03/15/2023
Stem Cell Transplantation: Blood Cancers - (0533) PDF 621kB 01/15/2024
Stem Cell Transplantation: Non-cancer Disorders - (0535) PDF 450kB 02/15/2024
Stem Cell Transplantation: Solid Tumors - (0534) PDF 352kB 01/15/2024
Strapping and Taping - (CPG143) PDF 686kB 12/03/2023
Subtalar Joint Implantation (Subtalar Arthroereisis) - (0486) PDF 246kB 10/15/2023
Surgical Treatment for Chest Wall Deformities - (0309) PDF 263kB 07/15/2023
Surgical Treatment for Hyperhidrosis - (0037) PDF 256kB 01/15/2024
Surgical Treatments for Obstructive Sleep Apnea - (0158)

PDF 383kB 10/15/2023
T
Temporomandibular Joint (TMJ) Disorder Surgery - (0156) PDF 273kB 12/15/2023
Tests for the Evaluation of Preterm Labor and Premature Rupture of Membranes - (0099) PDF 446kB 07/15/2023
Thermal Shrinkage - (0176) PDF 231kB 07/15/2023
Thymus Tissue Transplantation - (0561) PDF 192kB 08/15/2023
Tilt Table Testing and Computerized Dynamic Posturography - (0270) PDF 243kB 12/15/2023
Tissue Engineered Skin Substitutes - (0068) PDF 158kB 08/15/2023
Total Ankle Arthroplasty/Replacement - (0285) PDF 254kB 02/15/2024
Transcatheter Ablation for the Treatment of Supraventricular Tachycardia in Adults - (0529) PDF 331kB 04/15/2023
Transcatheter Closure of Cardiovascular Defects - (0011) PDF 119kB 11/15/2023
Transcatheter Heart Valve Procedures - (0501) PDF 917kB 12/03/2023
Transcranial Magnetic Stimulation - (EN0383) PDF 594kB 08/23/2023
Transition of Care Service Requests For New Customers - (UM-35) PDF 2950kB 01/08/2024
Transplantation Donor Charges - (0132) PDF 248kB 11/15/2023
Transthoracic Echocardiography in Adults - (0510) PDF 534kB 02/15/2024
Transthoracic Echocardiography in Children - (0523) PDF 808kB 02/15/2024
Transvaginal Ultrasound, Non-Obstetrical - (0398) PDF 322kB 12/15/2023
Treatment of Cutaneous and/or Deep Tissue Hemangioma, Port Wine Stain and Other Vascular Lesions - (0313) PDF 331kB 05/15/2023
Tumor In Vitro Chemosensitivity and Chemoresistance Assays - (0203)

PDF 312kB 05/15/2023
U
Ultrasound in Pregnancy (including 3D, 4D and 5D Ultrasound) - (0142) PDF 287kB 06/15/2023
Umbilical Cord Blood Banking - (0466)

PDF 216kB 06/15/2023
V
Vagus Nerve Stimulation (VNS) - (0350) PDF 428kB 12/15/2023
Varicose Vein Treatments - (0234) PDF 664kB 11/15/2023
Vascularized Composite Allograft (VCA) Transplant - (0560) PDF 262kB 01/15/2024
Venous Angioplasty and/or Stent Placement in Adults - (0541) PDF 499kB 06/15/2023
Ventricular Assist Devices (VADs), Percutaneous Cardiac Support Systems and Total Artificial Heart - (0054) PDF 652kB 12/15/2023
Vitamin D Testing - (0526)

PDF 435kB 12/03/2023
W
Wearable Cardioverter Defibrillator and Automatic External Defibrillator - (0431) PDF 435kB 12/03/2023
Wheelchairs/Power Operated Vehicles - (0030) PDF 495kB 12/03/2023
Whole Exome and Whole Genome Sequencing for Non-Cancer Indications - (0519) PDF 432kB 01/15/2024
Whole Exome Sequencing Recommendation Form

Online Resource 04/03/2017