| Policy Title | Policy # | Review Date |
|---|
| Air Ambulance (PDF) | CP.MP.175 | 22-Aug-22 |
| Bariatric Surgery (PDF) | CP.MP.37 | 8/30/2022 |
| Biofeedback (PDF) | CP.MP.168 | 6-Dec-22 |
| Burn Surgery (PDF) | CP.MP.186 | 19-Dec-23 |
| Caudal or Interlaminar Epidural Steroid Injections (PDF) | CP.MP.164 | 23-Aug-22 |
Cell-free Fetal DNA Testing (PDF)
Cell-free Fetal DNA Testing Addendum (PDF)
| CP.MP.84
CP.MP.84_Addendum
| 29-Oct-21
|
| Cochlear Implant Replacements (PDF) | CP.MP.14 | 20-Aug-22 |
| Cosmetic and Reconstructive Procedures (PDF) | CP.MP.31 | 4-Nov-22 |
| Dental Anesthesia (PDF) | CP.MP.61 | 4-Nov-22 |
Diaphragmatic/Phrenic Nerve Stimulation (PDF)
Diaphragmatic/Phrenic Nerve Stimulation Addendum (PDF)
| CP.MP.203
CP.MP.203 Addendum
| 13-Jan-23
|
Durable Medical Equipment (PDF)
Durable Medical Equipment Addendum (PDF)
| CP.MP.107
CP.MP.107 Addendum
| 13-Jan-23
|
| Experimental Technologies (PDF) | CP.MP.36 | 23-Aug-22 |
| Fecal Incontinence Treatments (PDF) | CP.MP.137 | 22-Aug-22 |
| Fertility preservation (PDF) | CP.MP.130 | 4-Oct-22 |
| Gastric Electrical Stimulation (PDF) | CP.MP.40 | 23-Aug-22 |
| Gender -Affirming Procedures (PDF) | CP.MP.95 | 1-Sep-22 |
Genetic Testing General Approach to Genetic Testing (PDF)
Genetic Testing General Approach to Genetic Testing Addendum (PDF)
| CP.MP.222
CP.MP.222 Addendum
| 10-Mar-22
|
Genetic Testing Hematologic Condition (non-cancerous) (PDF)
Genetic Testing Hematologic Condition (non-cancerous) Addendum (PDF)
| CP.MP.224
CP.MP.224 Addendum
| 12-Sep-22
|
Genetic Testing Hereditary Cancer Susceptibility (PDF)
Genetic Testing Hereditary Cancer Susceptibility Addendum (PDF)
| CP.MP.225
CP.MP.225 Addendum
| 10-Mar-22
|
Genetic Testing Pharmacogenetics (PDF)
Genetic Testing Pharmacogenetics Addendum (PDF)
| CP.MP.232
CP.MP.232 Addendum
| 10-Mar-22
|
Genetic Testing Prenatal Diagnosis (PDF)
Genetic Testing Prenatal Diagnosis_Addendum (PDF)
| CP.MP.235
CP.MP.235 Addendum
| 10-Mar-22
|
| Home Birth (PDF) | CP.MP.136 | 22-Aug-22 |
| Hyperhydrosis Treatments (PDF) | CP.MP.62 | 30-Aug-22 |
| Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) | CP.MP.180 | 19-Dec-22 |
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
| CP.MP.160
CP.MP.160_Addendum
| 5-Mar-22
|
| Intradiscal Steroid Injections for Pain Management (PDF) | CP.MP.167 | 1-Sep-22 |
Laser Therapy for Skin Conditions (PDF)
Laser Therapy for Skin Conditions Addendum (PDF)
| CP.MP.123
CP.MP.123 Addendum
| 22-Aug-22
|
| Low-Frequency ultrasound and noncontact normothermic wound therapy (PDF) | CP.MP.139 | 30-Aug-22 |
| Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) | CP.MP.144 | 19-Dec-22 |
Nerve Blocks and Neurolysis for Pain Management (PDF)
Nerve Blocks and Neurolysis for Pain Management (PDF)
| CP.MP.170
CP.MP.170_Addendum
| 1-Sep-22
|
| Neuromusclar and Peroneal Nerve Electrical Stimulation (NMES) | CP.MP.48 | 22-Jul-22 |
| Optic nerve decompression surgery (PDF) | CP.MP.128 | 28-Jul-22 |
| Orthognathic Surgery (PDF) | CP.MP.202 | 4-Nov-22 |
Osteogenic Stimulation (PDF)
Osteogenic Stimulation Addendum (PDF) | CP.MP.194
CP.MP.194_Addendum | 4-Oct-22
|
Phototherapy for Neonatal Hyperbilirubinemia (PDF)
Phototherapy for Neonatal Hyperbilirubinemia Addendum (PDF) | CP.MP.150
CP.MP.150_Addendum | 4-Nov-22
|
| Reduction Mammoplasty and Gynecomastia Surgery (PDF) | CP.MP.51 | 28-Jul-22 |
Repair of Nasal Valve Compromise (PDF)
Repair of Nasal Valve Compromise Addendum (PDF) | CP.MP.210
CP.MP.210_Addendum | 1-Jun-22
|
| Sacroiliac Joint Interventions for Pain Management (PDF) | CP.MP.166 | 1-Sep-22 |
| Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF) | CP.MP.146 | 22-Aug-22 |
| Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF) | CP.MP.165 | 1-Sep-22 |
| Total Parenteral Nutrition and Intradialytic Parental Nutrition (PDF) | CP.MP.163 | 5-May-22 |
| Transcatheter closure of patent foramen ovale (PDF) | CP.MP.151 | 19-Dec-22 |
Transplant Authorizations (PDF)
Transplant Authorizations Addendum (PDF) | CC.UM.18
CC.UM.18_Addendum | 01-30-23
|
| Trigger Point Injections for Pain Management (PDF) | CP.MP.169 | 1-Sep-22 |
