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Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^® and Keystone Health Plan^® Central. Independent licensees of the BlueCross BlueShield Association serving 21 counties in Central Pennsylvania and the Lehigh Valley. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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Medical Policies

Preauthorization for acute inpatient care, long term acute care hospital (LTACH), select procedures and select behavioral health services will be conducted using Change Healthcare's InterQual^® criteria. InterQual criteria are an industry standard set of objective evidence-based utilization management (UM) criteria for level of care placement and medical necessity determinations, including length of stay. These criteria are specific and comprehensive clinical guidelines developed by a highly trained clinical team who performs unbiased, systematic review and clinical appraisal of the evidence to help ensure the criteria reflect the best available clinical evidence. The criteria are updated frequently to remain current with the latest evidence.

Preauthorization for select substance use disorder services will be performed using the American Society of Addiction Medicine (ASAM) criteria.

ASAM criteria are an industry standard collection of guidelines for level of care placement and medical necessity determinations, including length of stay for substance use disorder services.

Find the medical policy you need in the library below. If medical policy is not located, please refer to the list of specialized services to confirm if medical necessity review is needed.

For specialized services administered by independent companies on behalf of Capital Blue Cross:

High Tech Radiology including Cardiac Imaging and Radiation Oncology
Laboratory Services
Molecular Lab Management Services – Effective January 1, 2026, EviCore’s management of preauthorization for outpatient molecular and genomic tests will be expanded to include Capital Blue Cross Administrative Services Only (ASO) members. (select ASO groups excluded). As of November 1, 2025, EviCore began managing these services for Commercial Fully Insured, CHIP, and Medicare Advantage members.
Musculoskeletal policies including hip, knee, shoulder and spine related services
Select Diagnostic and Surgical Cardiology Services

You can also view the out-of-area medical policies.

Specialty Injectables:

Effective January 1, 2026, Prime Medical Pharmacy Solutions¹ (Prime MPS) will manage services related to specialty medical injectable drugs, on behalf of Capital.

Specialty injectable drugs may require preauthorization through Prime MPS. Please refer to the single source preauthorization code list. Additionally, some drugs may have a site of service requirement.

To learn more about coverage criteria, including Drug Infusion Site of Service requirements, you may access Prime’s medical drug policies.

¹On behalf of Capital Blue Cross, Prime Medical Pharmacy Solutions (Prime MPS), a division of Prime Therapeutics Management LLC an independent company, provides medical specialty drug management services.

Medicare Information:

For additional Medicare coverage and policy information, please review the Medicare Medical Policy page.

Search active and retired medical policies

Medical Policy Library — sortable and filterable table
Policy number	Category	Policy title	Policy type
MP 1.012	Surgery	Abdominoplasty and Panniculectomy	Active
MP 2.376	Medicine	Ablation of Peripheral Nerves to Treat Pain	Active
MP 2.087	Medicine	Actigraphy	Active
MP 2.390	Medicine	Adjunctive Techniques for Screening, Surveillance and Risk Classification of Barrett Esophagus and Esophageal Dysplasia	Active
MP 6.056	Durable Medical Equipment	Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynstoses	Active
MP 3.017	Ancillary Services	Air and Water Ambulance Services	Active
MP 6.015	Ancillary Services	Airway Clearance Devices	Active
MP 2.001	Medicine	Allergy Testing and Immunotherapy	Active
MP 9.056	Transplant	Allogeneic HCT for Myelodysplastic Syndromes and Myeloproliferative Neoplasms	Active
MP 9.055	Transplant	Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias	Active
MP 1.159	Surgery	Amniotic Membrane and Amniotic Fluid	Active
MP 2.359	Medicine	Analysis of MGMT Promotor Methylation in Malignant Gliomas	Active
MP 6.062	Durable Medical Equipment	Ankle-Foot and Knee-Ankle-Foot Orthoses	Active
MP 2.149	Medicine	Aqueous Shunts and Stents for Glaucoma	Active
MP 2.304	Medicine	Autism Spectrum Disorders	Active
MP 2.317	Medicine	BCR-ABL1 Testing in Chronic Myelogenous Leukemia (CML) and Acute Lymphoblastic Leukemia	Active
MP 1.157	Surgery	Balloon Dilation for the Eustachian Tube	Active
MP 1.119	Surgery	Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis and Recurrent Acute Rhinosinusitis	Active
MP 1.015	Surgery	Bariatric Surgery	Active
MP 1.142	Surgery	Baroreflex Stimulation Device	Active
MP 1.158	Surgery	Bio-Engineered Skin and Soft Tissue Substitutes	Active
MP 2.064	Medicine	Biofeedback and Neurofeedback Therapy	Active
MP 2.190	Medicine	Bioimpedance Devices for Detection and Management of Lymphedema	Active
MP 1.003	Surgery	Blepharoplasty, Repair of Brow Ptosis and Reconstructive Eyelid Surgery	Active
MP 2.081	Medicine	Bronchial Thermoplasty	Active
MP 2.158	Medicine	Cabazitaxel (Jevtana^®)	Active
MP 2.051	Medicine	Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting	Active
MP 2.258	Medicine	Carrier Screening for Genetic Diseases	Active
MP 7.028	OBGYN/Reproduction	Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss	Active
MP 2.267	Medicine	Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)	Active
MP 1.039	Surgery	Closure Devices for Patent Foramen Ovale and Atrial Septal Defects (ASD)	Active
MP 1.023	Surgery	Cochlear Implant	Active
MP 6.013	Durable Medical Equipment	Compression Devices for Treatment of Lymphedema and Peripheral Vascular Disease	Active
MP 1.106	Surgery	Computer Assisted Navigation for Orthopedic Procedures	Active
MP 5.062	Radiology/Imaging	Computer-Assisted Corneal Topography	Active
MP 2.093	Medicine	Confocal Laser Endomicroscopy	Active
MP 6.004	Durable Medical Equipment	Continuous Glucose Monitoring	Active
MP 6.039	Durable Medical Equipment	Continuous Passive Motion in the Home Setting	Active
MP 6.040	Durable Medical Equipment	Cooling Devices Used in the Outpatient Setting	Active
MP 2.028	Medicine	Corneal Collagen Cross-Linking	Active
MP 9.011	Transplant	Corneal Surgery (Formerly Corneal Transplant, Endothelial Keratoplasty, and Keratoprostheses)	Active
MP 1.004	Surgery	Cosmetic and Reconstructive Surgery	Active
MP 2.092	Medicine	Cranial Electrotherapy Stimulation and Auricular Electrostimulation	Active
MP 1.088	Surgery	Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone	Active
MP 1.121	Surgery	Cryosurgical Ablation of Primary or Metastatic Liver Tumors	Active
MP 2.234	Medicine	Cytochrome P450 Genotype Guided Treatment Strategy	Active
MP 1.042	Surgery	Deep Brain Stimulation	Active
MP 2.381	Medicine	Dengvaxia	Active
MP 1.092	Surgery	Dental and Oral Surgery Procedures Performed in a Facility	Active
MP 4.018	Other Treatments	Dermatologic Applications of Photodynamic Therapy	Active
MP 4.033	Other Treatments	Diagnosis and Treatment of Dry Eye Syndrome	Active
MP 5.048	Radiology/Imaging	Diagnosis and Treatment of Sacroiliac Joint Pain	Active
MP 2.045	Medicine	Diagnosis of Obstructive Sleep Apnea	Active
MP 2.050	Medicine	Diagnostic Testing and Risk Assessment for Alzheimer Disease (Biochemical and Genetic)	Active
MP 2.004	Medicine	Donor Lymphocyte Infusion for Hematologic Malignancies Treated with an Allogeneic HCT	Active
MP 4.041	Other Treatments	Dry Needling of Trigger Points for Myofascial Pain	Active
MP 6.026	Durable Medical Equipment	Durable Medical Equipment and Supplies (DME)	Active
MP 2.011	Medicine	Dynamic Posturography	Active
MP 5.051	Radiology/Imaging	Dynamic Spinal Visualization and Vertebral Motion Analysis	Active
MP 1.024	Surgery	Electrical Bone Growth Stimulation of the Appendicular Skeleton	Active
MP 1.150	Surgery	Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures	Active
MP 2.096	Medicine	Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter	Active
MP 2.063	Medicine	Electromyography and Nerve Conduction Studies	Active
MP 7.013	OBGYN/Reproduction	Endometrial Ablation	Active
MP 1.118	Surgery	Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus	Active
MP 1.090	Surgery	Endovascular Grafts for Abdominal Aortic Aneurysm	Active
MP 1.132	Surgery	Endovascular Stent Grafts for Disorders of the Thoracic Aorta	Active
MP 2.015	Medicine	Enteral Nutrition	Active
MP 4.014	Other Treatments	Epidural Steroid Injections for Back Pain and Facet Nerve Blocks	Active
MP 2.016	Medicine	Erectile Dysfunction	Active
MP 2.367	Medicine	Esketamine (Spravato™)	Active
MP 2.017	Medicine	Esophageal pH Monitoring	Active
MP 2.391	Medicine	Evaluation of Biomarkers for Alzheimer's Disease	Active
MP 4.029	Other Treatments	Evoked Potential Studies	Active
MP 2.386	Medicine	Expanded Access	Active
MP 4.002	Other Treatments	Experimental and Investigational Procedures	Active
MP 6.007	Medicine	External Infusion Pumps for Insulin Delivery and Artificial Pancreas Device	Active
MP 2.068	Medicine	Extracorporeal Photopheresis	Active
MP 2.034	Medicine	Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions	Active
MP 5.049	Radiology/Imaging	Facet Joint Denervation	Active
MP 2.018	Medicine	Foot Care Services	Active
MP 6.028	Durable Medical Equipment	Foot Orthotics and Other Podiatric Appliances	Active
MP 2.378	Medicine	Ganglion Impar Block	Active
MP 6.031	Durable Medical Equipment	Gas Permeable Scleral Contact Lens and Therapeutic Soft Contact Lens	Active
MP 2.069	Medicine	Gastric Electrical Stimulation	Active
MP 1.144	Surgery	Gender Affirming Surgery	Active
MP 2.245	Medicine	Gene Expression Based Assays for Cancers of Unknown Primary	Active
MP 2.315	Medicine	Gene Expression Profile Testing and Circulating Tumor DNA testing for Predicting Recurrence in Colon Cancer	Active
MP 2.280	Medicine	Gene Expression Profiling and Protein Biomarkers for the Management Diagnosis and Cancer Risk Assessment of Prostate Cancer	Active
MP 2.396	Medicine	Gene Expression Profiling for Cutaneous Melanoma	Active
MP 2.360	Medicine	Gene Expression Profiling for Uveal Melanoma	Active
MP 2.313	Medicine	Gene Expression Testing in Patients with Stable Ischemic Heart Disease	Active
MP 2.323	Medicine	General Approach to Evaluating the Utility of Genetic Panels	Active
MP 2.326	Medicine	General Approach to Genetic Testing	Active
MP 2.325	Medicine	Genetic Cancer Susceptibility Panels Using Next Generational Sequencing	Active
MP 2.320	Medicine	Genetic Testing for Alpha Thalassemia	Active
MP 2.251	Medicine	Genetic Testing for Alpha-1 Antitrypsin Deficiency	Active
MP 2.050	Medicine	Genetic Testing for Alzheimer Disease (Formerly Diagnostic Testing and Risk Assessment for Alzheimer Disease)	Active
MP 2.322	Medicine	Genetic Testing for CHARGE Syndrome	Active
MP 2.233	Medicine	Genetic Testing for Cardiac Ion Channelopathies	Active
MP 2.242	Medicine	Genetic Testing for DD, ID, Autism Spectrum Disorder and CA	Active
MP 2.242	Medicine	Genetic Testing for Developmental Delay-Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies	Active
MP 2.264	Medicine	Genetic Testing for Diagnosis and Management of Mental Health Conditions	Active
MP 2.257	Medicine	Genetic Testing for Duchenne and Becker Muscular Dystrophy	Active
MP 2.262	Medicine	Genetic Testing for Epilepsy	Active
MP 2.357	Medicine	Genetic Testing for FLT3, NPM1 and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia	Active
MP 2.321	Medicine	Genetic Testing for Facioscpulohumeral Muscular Dystrophy	Active
MP 2.246	Medicine	Genetic Testing for Familial Cutaneous Malignant Melanoma	Active
MP 2.362	Medicine	Genetic Testing for Fanconi Anemia	Active
MP 2.308	Medicine	Genetic Testing for Helicobacter Pylori Treatment	Active
MP 2.319	Medicine	Genetic Testing for Hereditary Hearing Loss	Active
MP 2.312	Medicine	Genetic Testing for Hereditary Hemochromatosis	Active
MP 2.318	Medicine	Genetic Testing for Hereditary Pancreatitis	Active
MP 2.363	Medicine	Genetic Testing for Heterozygous Familial Hypercholesterolemia	Active
MP 2.328	Medicine	Genetic Testing for Idiopathic Dilated Cardiomyopathy	Active
MP 2.253	Medicine	Genetic Testing for Inherited Thrombophilia	Active
MP 2.274	Medicine	Genetic Testing for Li-Fraumeni Syndrome	Active
MP 2.274	Medicine	Genetic Testing for Limb Girdle Muscular Dystrophies	Active
MP 2.310	Medicine	Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment	Active
MP 5.013	Radiology/Imaging	Genetic Testing for Lynch Syndrome and Inherited Colon Cancer Syndromes	Active
MP 2.260	Medicine	Genetic Testing for Macular Degeneration	Active
MP 2.331	Medicine	Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders	Active
MP 2.273	Medicine	Genetic Testing for Mitochondrial Disorders	Active
MP 2.358	Medicine	Genetic Testing for Neurofibromatosis	Active
MP 2.255	Medicine	Genetic Testing for PTEN Hamartoma Tumor Syndrome	Active
MP 2.276	Medicine	Genetic Testing for Pathogenic FMR1 Variants (Including Fragile X Syndrome)	Active
MP 2.248	Medicine	Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy	Active
MP 2.355	Medicine	Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies	Active
MP 2.247	Medicine	Genetic Testing of CADASIL Syndrome	Active
MP 2.307	Medicine	Genotype-Guided Tamoxifen Treatment	Active
MP 2.306	Medicine	Genotype-Guided Warfarin Dosing	Active
MP 2.311	Medicine	Genotyping for 9p21 Single Nucleotide Polymorphism to Predict Risk of Cardiovascular Disease and Aneurysm	Active
MP 2.393	Medicine	Germline And Somatic Biomarker Testing (Including Liquid Biopsy) For Targeted Treatment In Breast Cancer (Brca1, Brca2, Pik3ca, Ki-67, Ret, Braf, Esr1, Ntrk)	Active
MP 2.395	Medicine	Germline And Somatic Biomarker Testing (Including Liquid Biopsy) For Targeted Treatment In Ovarian Cancer (Brca1, Brca2, Homologous Recombination Deficiency, Ntrk)	Active
MP 2.394	Medicine	Germline And Somatic Biomarker Testing (Including Liquid Biopsy) For Targeted Treatment In Prostate Cancer (Brca1/2, Homologous Recombination Repair Gene Alterations, Ntrk Gene Fusion)	Active
MP 2.279	Medicine	Germline Genetic Testing for Gene Variants Associated with Breast Cancer in Individuals at High	Active
MP 2.211	Medicine	Germline Genetic Testing for Hereditary Breast_Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)	Active
MP 2.384	Medicine	Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1,CTNNA1)	Active
MP 2.392	Medicine	Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes	Active
MP 6.049	Durable Medical Equipment	H-Wave Electrical Stimulation	Active
MP 5.055	Radiology/Imaging	Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast Conserving Surgery	Active
MP 9.007	Transplant	Heart Transplant	Active
MP 9.014	Transplant	Heart/Lung Transplant	Active
MP 9.041	Transplant	Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia	Active
MP 9.040	Transplant	Hematopoietic Cell Transplantation for Acute Myeloid Leukemia	Active
MP 9.053	Transplant	Hematopoietic Cell Transplantation for Autoimmune Diseases	Active
MP 9.050	Transplant	Hematopoietic Cell Transplantation for CNS Embryonal Tumors, CNS Germ Cell Tumors and Ependymoma	Active
MP 9.038	Transplant	Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma	Active
MP 9.039	Transplant	Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia	Active
MP 9.047	Transplant	Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer	Active
MP 9.043	Transplant	Hematopoietic Cell Transplantation for Hodgkin Lymphoma	Active
MP 9.048	Transplant	Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults	Active
MP 9.042	Transplant	Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas	Active
MP 9.044	Transplant	Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome	Active
MP 9.045	Transplant	Hematopoietic Cell Transplantation for Primary Amyloidosis	Active
MP 9.054	Transplant	Hematopoietic Cell Transplantation for Solid Tumors of Childhood	Active
MP 9.046	Transplant	Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia	Active
MP 9.052	Transplant	Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors	Active
MP 6.001	Durable Medical Equipment	Hospital Beds, Accessories, and Pressure-Reducing Support Surfaces	Active
MP 2.070	Medicine	Hyperbaric Oxygen Therapy (HBO) (Formerly Hyperbaric Oxygen Pressurization)	Active
MP 2.021	Medicine	Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies	Active
MP 1.019	Surgery	Implantable Bone-Conduction and Bone-Anchored Hearing Prosthetic Devices	Active
MP 1.058	Surgery	Implantable Infusion Pumps for Pain and Spasticity	Active
MP 1.044	Surgery	Implantation of Intrastromal Corneal Ring Segments	Active
MP 4.012	Other Treatments	Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence	Active
MP 3.019	Ancillary Services	Inpatient Interfacility Transfers	Active
MP 2.079	Medicine	Intensive Pediatric Feeding Programs	Active
MP 6.047	Durable Medical Equipment	Interferential Current Stimulation	Active
MP 1.120	Surgery	Interventions for Progressive Scoliosis	Active
MP 6.058	Durable Medical Equipment	Intraocular Lenses, Spectacle Correction,and Iris Prosthesis	Active
MP 2.389	Medicine	Intraocular Radiotherapy for Age-Related Macular Degeneration	Active
MP 2.030	Medicine	Intraoperative Neurophysiologic Monitoring (Sensory Evoked Potentials, Motor Evoked Potentials, EEG Monitoring)	Active
MP 2.167	Medicine	Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders	Active
MP 2.026	Medicine	Intravenous Antibiotic Therapy for Lyme Disease	Active
MP 4.005	Other Treatments	Intravenous Chelation Therapy	Active
MP 2.159	Medicine	Intravitreal and Punctum Corticosteroid Implants	Active
MP 2.278	Medicine	Invasive Prenatal (Fetal) Diagnostic Testing	Active
MP 2.277	Medicine	Investigational Miscellaneous Genetic and Molecular Tests	Active
MP 8.001	Therapy	Investigational Physical Medicine And Specialized Physical Medicine Interventions (Outpatient)	Active
MP 1.162	Surgery	Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney or Lung	Active
MP 9.012	Transplant	Islet Transplantation	Active
MP 9.013	Transplant	Isolated Small Bowel Transplant and Small Bowel/Liver and Multivisceral Transplant	Active
MP 2.281	Medicine	JAK2, MPL, and CLR Mutation Analysis in Myeloproliferative Neoplasms	Active
MP 2.309	Medicine	KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy	Active
MP 2.316	Medicine	KRAS, NRAS, and BRAF Variant Analysis in Metastatic Colorectal Cancer	Active
MP 9.005	Transplant	Kidney Transplants, Pancreas Transplants, and Simultaneous Kidney/Pancreas Transplant	Active
MP 6.012	Durable Medical Equipment	Knee Braces	Active
MP 2.354	Medicine	Laboratory and Genetic Testing for Use of 5-Flourouracil in Patients with Cancer	Active
MP 7.027	OBGYN/Reproduction	Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids	Active
MP 4.047	Other Treatments	Laser Treatment for Vulvovaginal Atrophy and Vaginal Rejuvenation	Active
MP 1.008	Surgery	Laser Treatment of Port Wine Stains	Active
MP 2.046	Medicine	Light Therapies	Active
MP 9.006	Transplant	Liver Transplant and Combined Liver-Kidney Transplant	Active
MP 6.021	Durable Medical Equipment	Low Intensity Pulsed Ultrasound Fracture Healing Device	Active
MP 1.097	Surgery	Low Level Laser Therapy	Active
MP 6.042	Durable Medical Equipment	Lower Limb Prostheses	Active
MP 9.015	Transplant	Lung and Lobar Lung Transplant	Active
MP 6.027	Durable Medical Equipment	Lysis of Epidural Adhesions	Active
MP 1.145	Surgery	Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease	Active
MP 5.053	Radiology/Imaging	Magnetic Resonance-Guided Focused Ultrasound	Active
MP 5.011	Radiology/Imaging	Magnetoencephalography/Magnetic Source Imaging	Active
MP 5.008	Radiology/Imaging	Mammography (Including Computer Aided Detection Mammography and Positron Emission Mammography)	Active
MP 6.059	Durable Medical Equipment	Manual Wheelchairs and Accessories	Active
MP 4.038	Other Treatments	Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and other Respiratory Disorders	Active
MP 6.022	Durable Medical Equipment	Mechanical Insufflation Exsufflation Device	Active
MP 6.039	Durable Medical Equipment	Mechanical Stretching Devices for Contracture and Joint Stiffness	Active
MP 6.064	Durable Medical Equipment	Medical Management of Obstructive Sleep Apnea Syndrome	Active
MP 4.003	Other Treatments	Medical Necessity	Active
MP 2.304	Medicine	Medical Treatments of Autism Spectrum Disorders	Active
MP 2.090	Medicine	Microwave Tumor Ablation	Active
MP 2.275	Medicine	Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas	Active
MP 2.275	Medicine	Molecular Markers in Fine Needle Aspirates of the Thyroid	Active
MP 2.259	Medicine	Molecular Panel Testing of Cancers to Identify Targeted Therapies	Active
MP 2.377	Medicine	Molecular Testing for Germline Variants Associated with Ovarian Cancer (BRIP1, RAD51C, RAD51D, NBN)	Active
MP 2.266	Medicine	Molecular Testing for The Management of Pancreatic Cysts and Solid Pancreaticobiliary Lesions	Active
MP 2.375	Medicine	Molecular Testing in the Management of Pulmonary Nodules	Active
MP 2.231	Medicine	Morphometric Based Testing	Active
MP 2.387	Medicine	Multicancer Early Detection Testing	Active
MP 2.315	Medicine	Multigene Expression Assay for Predicting Recurrence in Colon Cancer	Active
MP 2.270	Medicine	Multimarker Serum Testing Related to Ovarian Cancer	Active
MP 5.054	Radiology/Imaging	Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure	Active
MP 2.094	Medicine	Navigated Transcranial Stimulation (nTMS)	Active
MP 4.004	Other Treatments	Negative Pressure Wound Therapy in the Outpatient Setting	Active
MP 8.012	Therapy	Neural Therapy	Active
MP 6.051	Durable Medical Equipment	Neuromuscular and Functional Neuromuscular Electrical Stimulation	Active
MP 2.379	Medicine	Next-Generation Sequencing For The Assessment of Measurable Residual Disease	Active
MP 3.009	Ancillary Services	Non-Emergent Ground Transport Services	Active
MP 7.026	OBGYN/Reproduction	Noncontraceptive Use of Intrauterine Devices (IUDs)	Active
MP 2.261	Medicine	Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA	Active
MP 2.256	Medicine	Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell Free DNA	Active
MP 2.252	Medicine	Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease	Active
MP 2.071	Medicine	Nonpharmacologic Treatment of Rosacea	Active
MP 2.372	Medicine	Occipital Nerve Stimulation	Active
MP 2.103	Medicine	Off-Label Use of Medications and other Interventions	Active
MP 4.019	Other Treatments	Oncological Applications of Photodynamic Therapy including Barrett's Esophagus	Active
MP 2.083	Medicine	Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)	Active
MP 2.056	Medicine	Ophthalmologic Techniques That Evaluate the Posterior Eye Segment	Active
MP 2.085	Medicine	Optical Coherence Tomography (OCT) of the Anterior Eye Segment	Active
MP 2.066	Medicine	Optical Diagnostic Devices for Evaluation of Skin Lesions Suspected of Malignancy	Active
MP 2.383	Medicine	Orphan Drugs and Humanitarian Use Devices	Active
MP 1.101	Surgery	Orthognathic Surgery	Active
MP 4.039	Other Treatments	Orthopedic Applications of Platelet Rich Plasma	Active
MP 2.080	Medicine	Orthopedic Applications of Stem Cell Therapy (Including Allograft and Bone Substitute Products Used with Autologous Bone Marrow)	Active
MP 2.005	Medicine	Other Therapies of Hyperhidrosis	Active
MP 2.092	Medicine	PENFS, CES, Auricular Electrostimulation, and External Trigeminal Nerve Stimulation	Active
MP 2.097	Medicine	Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain	Active
MP 6.024	Durable Medical Equipment	Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence	Active
MP 2.397	Medicine	Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome	Active
MP 6.050	Durable Medical Equipment	Percutaneous Electrical Nerve Stimulation (PENs) and Percutaneous Neuromodulation Therapy (PNT)	Active
MP 1.124	Surgery	Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation	Active
MP 1.134	Surgery	Percutaneous and Implantable Tibial Nerve Stimulation	Active
MP 1.141	Surgery	Peripheral Subcutaneous Field Stimulation (PSFS)	Active
MP 1.109	Surgery	Periureteral Bulking Agents as Treatment of Vesicoureteral Reflux	Active
MP 1.143	Surgery	Peroral Endoscopic Myotomy (POEM) for Treatment of Esophageal Achalasia	Active
MP 2.218	Medicine	Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines	Active
MP 4.008	Other Treatments	Photocoagulation Therapy for Treatment of AMD	Active
MP 9.001	Transplant	Placental/Umbilical Cord Blood as Source of Stem Cells	Active
MP 4.031	Other Treatments	Plasma Exchange (PE)	Active
MP 2.335	Medicine	Polysomnography for Non-Respiratory Sleep Disorders	Active
MP 5.008	Radiology/Imaging	Positron Emission Mammography	Active
MP 6.053	Durable Medical Equipment	Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis	Active
MP 6.037	Durable Medical Equipment	Power Wheelchairs, Power Operated Vehicles (POV) and Related Options and Accessories	Active
MP 7.009	OBGYN/Reproduction	Preimplantation Genetic Testing	Active
MP 3.004	Ancillary Services	Private Duty Nursing Services	Active
MP 2.053	Medicine	Procedures for the Treatment of Gastroesophageal Reflux Disease (Formerly Surgical Treatments for Gastroesophageal Reflux Disease)	Active
MP 2.061	Medicine	Prolotherapy	Active
MP 1.147	Surgery	Prostatic Urethral Lift	Active
MP 2.343	Medicine	Proteogenomic Testing for Patients With Cancer	Active
MP 2.337	Medicine	Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer	Active
MP 1.084	Surgery	Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors	Active
MP 1.055	Surgery	Radiofrequency Ablation of Primary or Metastatic Liver Tumors	Active
MP 2.033	Medicine	Recombinant and Autologous Platelet Derived Growth Factors as a Treatment of Wound Healing and Other Non-Orthopedic Conditions	Active
MP 1.103	Surgery	Reconstructive Breast Surgery Including Management of Breast Implants, External Breast Prosthesis and Post Mastectomy Bras	Active
MP 1.013	Surgery	Reduction Mammoplasty for Breast-Related Symptoms	Active
MP 1.156	Surgery	Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy	Active
MP 2.088	Medicine	Rhinomanometry and Acoustic/Optical Rhinometry	Active
MP 1.033	Surgery	Sacral Nerve Neuromodulation-Stimulation	Active
MP 5.021	Radiology/Imaging	Scintimammography and Gamma Imaging of the Breast and Axilla	Active
MP 2.176	Medicine	Self Administered Medications	Active
MP 1.130	Surgery	Semi-Implantable and Fully Implantable Middle Ear Hearing Aid	Active
MP 8.011	Therapy	Sensory Integration Therapy and Auditory Integration Therapy	Active
MP 2.222	Medicine	Serum Antibody Markers for Diagnosing Inflammatory Bowel Disease	Active
MP 2.269	Medicine	Serum Biomarkers for Human Epididymis Protein 4 (HE4)	Active
MP 1.094	Surgery	Skin Contact Monochromatic Infrared Energy for Treatment of Cutaneous Ulcers, Diabetic Neuropathy and Miscellaneous Musculoskeletal Conditions	Active
MP 2.241	Medicine	Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Therapy in Non-Small Cell Lung	Active
MP 2.316	Medicine	Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Metastatic Colorec	Active
MP 2.388	Medicine	Somatic Biomarker Testing For Immune Checkpoint Inhibitor Therapy (MSIMMR, PD-L1, TMB)	Active
MP 2.316	Medicine	Somatic Genetic Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Metastatic Colorectal Cancer	Active
MP 2.364	Medicine	Somatic Genetic Testing to Select Individuals with Melanoma or Glioma for Targeted Therapy or Immunotherapy	Active
MP 8.002	Therapy	Speech Therapy (Outpatient)	Active
MP 4.046	Other Treatments	Sphenopalatine Ganglion Block	Active
MP 1.069	Surgery	Spinal Cord and Dorsal Root Ganglion Stimulation	Active
MP 6.063	Durable Medical Equipment	Spinal Orthoses (other than for Scoliosis)	Active
MP 2.089	Medicine	Stem Cell Therapy for Peripheral Arterial Disease	Active
MP 2.373	Medicine	Step Therapy Treatment of Stage Four, Advanced Metastatic Cancer and Severe Related Health Conditions	Active
MP 1.140	Surgery	Steroid-Eluting Sinus Stents and Implants	Active
MP 2.345	Medicine	Subcutaneous Hormone Pellet Implants	Active
MP 1.114	Surgery	Subtalar Arthroereisis	Active
MP 1.163	Surgery	Surgery for Groin Pain in Athletes	Active
MP 1.129	Surgery	Surgical Treatment of Gynecomastia	Active
MP 1.082	Surgery	Surgical Treatment of Heart Failure	Active
MP 1.128	Surgery	Surgical Treatment of Sleep Apnea and Snoring	Active
MP 1.161	Surgery	Surgical Treatments for Breast Cancer Related Lymphedema	Active
MP 2.053	Medicine	Surgical Treatments for Gastroesophageal Reflux Disease	Active
MP 6.045	Durable Medical Equipment	Sympathetic Therapy for the Treatment of Pain	Active
MP 1.160	Surgery	Synthetic Cartilage Implants for the First Metatarsophalangeal Joint	Active
MP 2.066	Medicine	Technologies for the Evaluation of Skin Lesions Suspected of Malignancy	Active
MP 1.164	Surgery	Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia	Active
MP 2.062	Medicine	Temporomandibular Joint Disorder	Active
MP 6.061	Durable Medical Equipment	Therapeutic Shoes for Persons with Diabetes	Active
MP 1.086	Surgery	Thermal Capsulorrhaphy as a Treatment of Joint Instability	Active
MP 5.017	Radiology/Imaging	Thermography	Active
MP 6.046	Durable Medical Equipment	Threshold Electrical Stimulation as a Treatment of Motor Disorders	Active
MP 1.134	Surgery	Tibial Nerve Stimulation	Active
MP 1.026	Surgery	Total Artificial Hearts and Implantable Ventricular Assist Devices	Active
MP 6.020	Durable Medical Equipment	Transcutaneous Electrical Nerve Stimulation and Transcutaneous Afferent Patterned Stimulation	Active
MP 2.053	Medicine	Transesophageal Endoscopic Therapies For Gastroesophageal Reflux Disease (Formerly Procedures For The Treatment Of Gastroesophageal Reflux Disease)	Active
MP 1.057	Surgery	Transmyocardial Revascularization	Active
MP 4.034	Other Treatments	Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence	Active
MP 1.061	Surgery	Treatment of Varicose Veins - Venous Insufficiency	Active
MP 1.061	Surgery	Treatments of the Prostate	Active
MP 2.072	Medicine	Trigger Point and Tender Point Injections	Active
MP 6.054	Durable Medical Equipment	Tumor Treating Fields Therapy	Active
MP 6.021	Durable Medical Equipment	Ultrasound Accelerated Fracture Healing Device	Active
MP 6.052	Durable Medical Equipment	Upper Limb Prostheses	Active
MP 2.249	Medicine	Use of Common Genetic Variants (Single Nucleotide Polymorphisms) to Predict Risk of Non-Familial Breast Cancer	Active
MP 1.034	Surgery	Vagus Nerve And Implantable Peripheral Nerve Stimulators	Active
MP 1.146	Surgery	Vagus Nerve Blocking Therapy for Treatment of Obesity	Active
MP 2.065	Medicine	Vertebral Axial Decompression	Active
MP 5.046	Radiology/Imaging	Vertebral Fracture Assessment and Biochemical Computed Tomography (Formerly Vertebral Fracture Assessment and Trabecular Bone Score)	Active
MP 1.136	Surgery	Vertical Expandable Prosthetic Titanium Rib	Active
MP 4.007	Other Treatments	Vision Therapy	Active
MP 5.037	Radiology/Imaging	Whole Body Dual X-Ray Absorptiometry to Determine Body Composition	Active
MP 2.324	Medicine	Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders	Active
MP 5.033	Radiology/Imaging	Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders	Active
MP 4.028	Other Treatments	Wound and Burn Management and Specialized Treatment Centers	Active
IC-0610NC		Aduhelm (Retired 11/1/2024)	Retired
MP 2.036	Medicine	Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry (Retired 4/1/2025)	Retired
		Amondys 45 (casimersen) PRIME (Retired 1/1/2023)	Retired
MP 2.359	Medicine	Analysis of MGMT Promoter Methylation in Malignant Gliomas (Retired 1/1/2024)	Retired
IC-0356		Aranesp^® (Retired 11/1/2023)	Retired
MP 1.002	Surgery	Augmentation Mammoplasty (Retired 8/1/2023)	Retired
MP 2.099	Medicine	Automated Point of Care Nerve Conduction Tests (Retired 1/1/2025)	Retired
MP 2.100	Medicine	Autonomic Nervous System Testing (retired 1/1/2026)	Retired
MP 1.017	Surgery	Bio-Engineered Skin and Soft Tissue Substitutes (Retired 4/1/2024)	Retired
IC-0561		Blenrep^® (Retired 11/1/2024)	Retired
MP 2.370	Medicine	Brexanolone for Postpartum Depression (Retired 3/1/2023)	Retired
MP 1.122	Surgery	Bronchial Valves (Retired 1/1/2026)	Retired
MP 2.271	Medicine	CA-125 (Retired 7/1/2025)	Retired
MP 2.007	Medicine	Cardiac Intervention Therapy for the Treatment of Heart Failure (Retired 4/1/2025)	Retired
MP 8.005	Therapy	Cardiac Rehabilitation In The Outpatient Setting (Retired 9/1/2025)	Retired
MP 1.081	Surgery	Cardioverter Defibrillators (Implantable and External) (Retired 4/1/2025)	Retired
MP 8.007	Therapy	Cognitive Rehabilitation (Retired 11/1/2025)	Retired
MP 1.106	Surgery	Computer Assisted Navigation for Orthopedic Procedures (retired 9/1/2024)	Retired
MP 4.048	Other Treatments	Coverage with Evidence Development (Retired 6/1/2025)	Retired
MP 2.380	Medicine	Diagnosis and Treatment of Post Acute COVID (PASC) (Retired 8/1/2025)	Retired
MP 3.016	Ancillary Services	Drug Infusion Site of Service (Retired 1/1/2026)	Retired
MP 6.048	Durable Medical Equipment	Electrical Stimulation for the Treatment of Arthritis and Miscellaneous Conditions (Retired 2/1/2025)	Retired
MP 2.032	Medicine	Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) (Retired 7/1/2025)	Retired
MP 1.149	Surgery	Endovascular Therapies for Extracranial Vertebral Artery Disease (Retired 4/1/2025)	Retired
MP 2.014	Medicine	Enhanced External Counterpulsation (Retired 5/1/2025)	Retired
IC-0357		Epoetin alfa: Epogen^®; Procrit^®; Retacrit^® (Retired 11/1/2023)	Retired
MP 2.016	Medicine	Erectile Dysfunction (Effective 7/1/2024)	Retired
		Exondys 51 (eteplirsen) PRIME (Retired 1/1/2023)	Retired
MP 2.369	Medicine	Fecal Microbiota Transplant (Retired 6/1/2024)	Retired
MP 1.152	Surgery	Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis (Retired 7/1/2025)	Retired
AHS M2058		Genetic Testing for Adolescent Idiopathic Scoliosis (Retired 10/1/2023)	Retired
MP 2.361	Medicine	Genetic Testing for Statin-Induced Myopathy (Retired 5/1/2025)	Retired
MP 2.279	Medicine	Germline Genetic Testing for Gene Variants Associate with Breast Cancer in Individuals at High B (Retired 8/1/2024)	Retired
		Golodirsen PRIME (Retired 1/1/2023)	Retired
MP 7.019	OBGYN/Reproduction	Home Uterine Activity Monitoring (Retired 11/1/2024)	Retired
MP 5.047	Radiology/Imaging	Ingestible pH and Pressure Capsule (Retired 7/1/2025)	Retired
MP 1.151	Surgery	Interspinous Fixation (Fusion) Devices (Retired 11/1/2023)	Retired
MP 4.013	Other Treatments	Iontophoresis Phonophoresis (Retired 12/1/2025)	Retired
MP 2.146	Medicine	Iron Replacement Products Including Ferumoxytol (Feraheme) and Ferric Carboxymaltose Injection (Retired 10/1/2023)	Retired
MP 1.127	Surgery	Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation (Retired 4/1/2025)	Retired
MP 4.024	Other Treatments	Lipid Apheresis (Effective 2/1/2024)	Retired
MP 8.006	Therapy	Manipulation Under Anesthesia (Retired 2/1/2025)	Retired
MP 2.329	Medicine	Measurement of Serum Antibodies to Selected Biologic Agents (Retired 7/1/2023)	Retired
MP 2.303	Medicine	Medications Used Under Heavy Sedation or General Anesthesia for Opioid Use Disorder (Retired 6/1/2025)	Retired
IC-0359		Mircera^® (Retired 11/1/2023)	Retired
MP 2.377	Medicine	Molecular Testing for Germline Variants Associated with Ovarian Cancer (BRIP1, RAD51C, RAD51D, N (Retired 8/1/2024)	Retired
MP 2.231	Medicine	Morphometric-Based Testing (Effective 4/1/2023)	Retired
MP 2.330	Medicine	Multi-Biomarker Disease Activity Blood Test for Rheumatoid Arthritis (Retired 10/1/2023)	Retired
MP 5.054	Radiology/Imaging	Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure (Retired 6/1/2024)	Retired
MP 4.027	Other Treatments	Neuropsychological Testing for Medical Purposes (Retired 7/1/2025)	Retired
MP 2.256	Medicine	Noninvasive Prenatal Screening for Fetal Aneuploidies Microdeletions Single Gene Disorders and Twin Zygosity using Cell Free Fetal DND (Retired 8/1/2023)	Retired
MP 8.004	Therapy	Occupational Therapy (Outpatient) (Retired 1/1/2026)	Retired
MP 3.015	Ancillary Services	Office Based Procedures Performed in a Facility (Retired 10/1/2023)	Retired
MP 2.385	Medicine	Olinvyk (oliceridine) (Retired 7/1/2025)	Retired
MP 8.008	Therapy	Outpatient Pulmonary Rehabilitation (Retired 10/1/2025)	Retired
MP 1.116	Surgery	Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome (Retired 11/1/2024)	Retired
IC-0595		Pepaxto^® (Retired 11/1/2023)	Retired
MP 3.004	Ancillary Services	Private Duty Nursing Services (Retired 8/1/2024)	Retired
MP 1.154	Surgery	Procedures Completed in an Ambulatory Surgery Center Using General or Regional Anesthesia (Retired 1/1/2026)	Retired
MP 4.009	Other Treatments	Procedures of Questionable Current Usefulness (Retired 6/1/2025)	Retired
MP 6.018	Durable Medical Equipment	Prosthetics and Accessories (Retired 12/1/2024)	Retired
MP 2.095	Medicine	Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit-Hyperactivity Disorder (Retired 5/1/2025)	Retired
MP 5.022	Radiology/Imaging	Radioimmunoscintigraphy (Monoclonal Antibody Imaging) with Indium 111 Capromab Pendetide for Prostate Cancer (Retired 5/1/2023)	Retired
MP 4.049	Other Treatments	Rapid Response to Requests for New Interventions or Interventions with New Applications During Policy Development and Review (Retired 11/1/2023)	Retired
MP 6.060	Durable Medical Equipment	Retinal Prosthesis (Retired 1/1/2025)	Retired
MP 2.086	Medicine	Retinal Telescreening for Diabetic Retinopathy (Retired 1/1/2026)	Retired
MP 6.032	Durable Medical Equipment	Speech Generating Devices (Retired 11/1/2025)	Retired
MP 4.032	Other Treatments	Suprachoroidal Delivery of Pharmacologic Agents (Effective 2/1/2024)	Retired
MP 2.057	Medicine	T-Wave Alternans Testing (Retired 10/1/2025)	Retired
MP 4.044	Other Treatments	Telestroke (Retired 6/1/2025)	Retired
AHS – M2141		Testing of Homocysteine Metabolism-Related Conditions (Retired 5/1/2023)	Retired
MP 1.135	Surgery	Transcatheter Aortic Valve Implantation for Aortic Stenosis (Retired 4/1/2025)	Retired
MP 1.153	Surgery	Transcatheter Mitral Valve Procedures (Retired 4/1/2025)	Retired
MP 1.139	Surgery	Transcatheter Pulmonary Valve Implantation (Retired 4/1/2025)	Retired
MP 2.382	Medicine	Treatment for Duchenne Muscular Dystrophy (Retired 1/1/2025)	Retired
MP 1.095	Surgery	Treatment of Menieres and Sudden Hearing Loss (Retired 8/1/2025)	Retired
MP 2.038	Medicine	Treatment of Tinnitus (Retired 10/1/2025)	Retired
MP 2.078	Medicine	Ultrafiltration in Decompensated Heart Failure (Retired 4/1/2025)	Retired
MP 5.036	Radiology/Imaging	Ultrasonographic Measurement of Carotid Intimal Medial Thickness as an Assessment of Subclinical Atherosclerosis (Retired 11/1/2025)	Retired
		Viltepso (viltolarsen) PRIME (Retired 1/1/2023)	Retired
AHS – G2133		ZIKA Virus Risk Assessment (Retired 11/1/2023)	Retired
MP 2.143	Medicine	Zoledronic Acid (Reclast, Zometa) (Retired 11/1/2024)	Retired
MP 2.010	Medicine	Clinical Trials (Retired 2/1/2026)	Retired
MP 3.008	Ancillary Services	Parenteral Nutrition (Retired 2/1/2026)	Retired
MP 2.371	Medicine	Therapeutic Radiopharmaceuticals for Neuroendocrine Tumors (Retired 2/1/2026)	Retired
MP 2.208	Medicine	Viral Tropism Testing (Retired 2/1/2026)	Retired

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