| Policy |
Effective End Date |
MCP 011 Lumbar Artificial Intervertebral Disc Replacement - Effective 4/22/24
|
4/10/25 |
MCP 051 Genetic Testing - Effective 2/24/25
|
4/10/25 |
MCP 133 Ambulatory and Video EEG Monitoring Outpatient Setting - Effective 5/1/24
|
4/10/25 |
MCP 338 Plantar Fasciitis Treatment - Effective 5/1/24
|
4/10/25 |
MCP 341 Smart Watch Photoplethysmography (PPG) for Detection of Atrial Fibrillation - Effective 5/1/24
|
4/10/25 |
MCP 344 Ketogenic Diet for Treatment of Intractable Seizures - Effective 5/1/24
|
4/10/25 |
MCP 350 MyoPro Orthosis - Effective 5/1/24
|
4/10/25 |
MCP 357 Skin and Soft Tissue Substitutes - Effective 2/24/25
|
4/10/25 |
MCP 397 Moleculight Wound Care Device - Effective 7/13/24
|
4/10/25 |
MCP 402 Plantar Fasciitis Surgery - Effective 7/13/24
|
4/10/25 |
MCP 407 Wound Vac (NPWT) - Effective 5/1/24
|
4/10/25 |
MCP 700 Foot Surgery-Bunionectomy - Effective 2/24/25
|
4/10/25 |
MCP 701 Foot Surgery-Hallux Rigidus - Effective 7/13/24
|
4/10/25 |
MCP 702 Foot Surgery-Lesser Toe Deformities-Hammer Mallet and Claw Toe - Effective 7/13/24
|
4/10/25 |
MCP 460 Tecelra (afamitresgene autoleucel) - Effective 2/24/25
|
4/5/25 |
MCP 413 Carvykti (ciltacabtagene autoleucel) - Effective 2/24/25
|
4/5/25 |
MCP 396 Yescarta (axicabtagene ciloleucel) - Effective 2/24/25
|
4/5/25 |
MCP 378 Tecartus (brexucabtagene autoleucel) - Effective 2/24/25
|
4/5/25 |
MCP 395 Kymriah (tisagenlecleucel) - Effective 2/24/25
|
4/5/25 |
Zulresso (brexanolone) C16319-A - Effective 8/22/24
|
3/21/25 |
Zinplava (bexlotoxumab) C14821-A – Effective 9/20/24
|
3/21/25 |
UM XRT 2009 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT – Effective 9/1/24
|
3/6/25 |
UM XRT 2010 Neutron and Proton Beam Policy – Effective 9/1/24
|
3/6/25 |
UM ONC_1332 Lutathera (lutetium Lu 177 dotatate) – Effective 9/1/24
|
2/24/25 |
Izervay (avacincaptad intravitreal) C26436-A – Effective 1/10/24
|
2/23/25 |
MCP 700 Foot Surgery-Bunionectomy - Effective 7/13/24
|
2/23/25
|
MCP 460 Tecelra (afamitresgene autoleucel) - Effective 11/3/24
|
2/23/25
|
MCP 446 Wheelchair Mounted Robotic Arm Devices – Effective 7/5/24
|
2/23/25
|
MCP 444 Implantable Peripheral Nerve and Nerve Field Stimulators for Chronic Pain – Effective 5/1/24
|
2/23/25
|
MCP 439 Vyjuvek (beremagene geperpavec) - Effective 9/20/24
|
2/23/25
|
MCP 427 Microwave Ablation of Lung and Liver Tumors - Effective 3/6/24
|
2/23/25
|
MCP 425 Hydrogel Spacer for Prostate Radiotherapy (SpaceOAR) - Effective 5/1/24
|
2/23/25
|
MCP 413 Carvykti (ciltacabtagene autoleucel) - Effective 9/20/24
|
2/23/25
|
MCP 412 Prescription Digital Therapeutics - Effective 7/13/24
|
2/23/25
|
MCP 410 Genicular Artery Embolization of the Knee for Osteoarthritis - Effective 5/1/24
|
2/23/25
|
MCP 408 Balloon Sinus Ostial Dilation Balloon Sinuplasty - Effective 3/6/24
|
2/23/25
|
MCP 403 Abecma (idecabtagene vicleucel) - Effective 9/20/24
|
2/23/25
|
MCP 400 Breyanzi (lisocabtagene maraleucel) - Effective 11/3/24
|
2/23/25
|
MCP 396 Yescarta (axicabtagene ciloleucel) - Effective 9/20/24
|
2/23/25
|
MCP 395 Kymriah (tisagenlecleucel) - Effective 9/20/24
|
2/23/25
|
MCP 386 Coolief Cooled Radiofrequency - Effective 3/6/24
|
2/23/25
|
MCP 383 IB-Stim Device for Abdominal Pain in Adolescents - Effective 3/6/24
|
2/23/25
|
MCP 378 Tecartus (brexucabtagene autoleucel) - Effective 9/20/24
|
2/23/25
|
MCP 357 Skin Substitutes - Effective 11/3/24
|
2/23/25
|
MCP 353 Electric Tumor Treatment Fields for Glioblastoma - Effective 5/1/24
|
2/23/25
|
MCP 351 Minimally Invasive Lumbar Decompression MILD for Spinal Stenosis - Effective 3/6/24
|
2/23/25
|
MCP 340 Implantable Neurostimulator for Central Sleep Apnea - Effective 5/1/24
|
2/23/25
|
MCP 339 Interspinous Process Fixation Devices for Spinal Fusion - Effective 5/1/24
|
2/23/25
|
MCP 321 Category III CPT Codes - Effective 3/6/24
|
2/23/25
|
MCP 318 Luxturna (voretigene neparvovec rzyl) - Effective 11/3/24
|
2/23/25
|
MCP 314 Genicular Radiofrequency Ablation RFA and Genicular Nerve Blocks for Chronic Knee Pain - Effective 5/1/24
|
2/23/25
|
MCP 312 Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Essential Tremor - Effective 4/22/24
|
2/23/25
|
MCP 293 Spinraza_nusinersen - Effective 1/11/25
|
2/23/25
|
MCP 132 Percutaneous Ventricular Assist Devices - Effective 3/15/24
|
2/23/25
|
MCP 051 Genetic Testing - Effective 12/15/24
|
2/23/25
|
MCP 312 Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Essential Tremor - Effective 2/24/25
|
2/18/25 |
MCP 006 Vagal Nerve Stimulation for Epilepsy - Effective 5/1/24
|
2/17/25
|
MCP 335 Deep Brain Stimulation DBS for Epilepsy - Effective 5/1/24
|
2/17/25
|
MCP 430 Responsive Neurostimulation (RNS) for Epilepsy - Effective 7/13/24
|
2/17/25 |
Xipere (triamcinolone ocular inj) C22222-A – Effective 1/15/24
|
2/14/25 |
Vyvgart (efgartigimod alfa) C23127-A – Effective 1/10/24
|
2/14/25
|
Vabysmo (faricimab) C22795-A – Effective 5/1/24
|
2/14/25
|
Tepezza (teprotumumab-trbw) C18462-A – Effective 1/10/24
|
2/14/25
|
Syfovre (pegcetacoplan intravitreal) C25311-A - Effective 1/14/24
|
2/14/25
|
Spevigo (spesolimab-sbzo) C20780-A – Effective 9/20/24
|
2/14/25
|
Saphnelo (anifrolumab) C21970-A – Effective 1/10/24
|
2/14/25
|
Rituxan (rituximab) and Biosimilars C10423-A - Effective 1/10/24
|
2/14/25
|
Retisert, Yutiq (fluocinolone acetonide) Intravitreal Implants C11728-A - Effective 9/20/24
|
2/14/25
|
Ranibizumab and Biosimilars (Lucentis, Byooviz, Cimerli) C10417-A – Effective 12/16/23
|
2/14/25
|
Prevymis (letermovir) C15922-A - Effective 5/1/24
|
2/14/25
|
Physician Administered Drugs C11251-A - Effective 1/7/24
|
2/14/25
|
Ozurdex (dexamethasone intravitreal implant) C9975-A – Effective 2/3/24
|
2/14/25
|
Off-Label Use of Drugs and Biologic Agents C4141-A – Effective 1/10/24
|
2/14/25
|
Nulojix (belatacept) C9968-A – Effective 1/15/24
|
2/14/25
|
Krystexxa (pegloticase) C2729-A – Effective 4/12/24
|
2/14/25
|
Iluvien (fluocinolone acetonide intravitreal implant) C11728-A - Effective 9/20/24
|
2/14/25
|
Hyaluronic Acid Injections C14676-A - Effective 1/10/24
|
2/14/25
|
Eylea (aflibercept) C5674-A – Effective 1/10/24
|
2/14/25
|
Dextenza (dexamethasone intracanalicular insert) C24242-A – Effective 9/20/24
|
2/14/25
|
Botulinum Toxin C8755-A - Effective 4/12/24
|
2/14/25
|
Benlysta (belimumab) C2722-A – Effective 1/10/24
|
2/14/25
|
Vyondys 53 (golodirsen) MNR C18466-A - Effective 9/21/24
|
2/10/25
|
Sunlenca (lenacapavir) C25206-A – Effective 4/12/24
|
2/10/25
|
Sivextro (tedizolid) C9353-A – Effective 4/12/24
|
2/10/25
|
Signifor (pasireotide diaspartate) C15367-A - Effective 10/25/24
|
2/10/25
|
Rolvedon, Neulasta, and Related Biosimilars C10419-A – Effective 10/25/24
|
2/10/25
|
Octreotide Policy No. C8839-A – Effective 11/10/24
|
2/10/25
|
Nuzyra (omadacycline tosylate) C15914-A - Effective 5/1/24
|
2/10/25
|
Leukine (sargramostim) C2439-A - Effective 4/12/24
|
2/10/25
|
Hereditary Angioedema Agents C21463-A – Effective 11/29/24
|
2/10/25
|
Filgrastim C2437-A – Effective 10/25/24
|
2/10/25
|
Exondys 51 (eteplirsen) MNR C18464-A - Effective 9/21/24
|
2/10/25
|
Cubicin (daptomycin) C10467-A - Effective 5/1/24
|
2/10/25
|
Amondys 45 (casimersen) MNR C21154-A - Effective 9/21/24
|
2/10/25
|
Xacduro (sulbactam and durlobactam) C26432-A – Effective 4/22/24
|
2/10/25
|
Vimizim (elosulfase alfa) C7068-A – Effective 10/25/24
|
2/10/25
|
Vibativ (telavancin) C14575-A - Effective 5/1/24
|
2/10/25
|
Ryplazim (plasminogen, human) C22238-A – Effective 10/25/24
|
2/10/25
|
Rebyota (fecal microbiota, live-jslm) C25213-A - Effective 4/12/24
|
2/10/25
|
Oxlumo (lumasiran) C21126-A – Effective 10/25/24
|
2/10/25
|
Onpattro (patisiran)_Tegsedi_(inotersen) C17894-A - Effective 10/25/24
|
2/10/25
|
Naglazyme (galsulfase) Policy No. C28288-A – Effective 11/3/24
|
2/10/25
|
Mepsevii (vestronidase alfa-vjbk) C17942-A - Effective 10/25/24
|
2/10/25 |
Lumizyme (alglucosidase alfa) C8716_A - Effective 10/25/24
|
2/10/25
|
Kanuma (sebelipase alfa) C9974-A - Effective 10/25/24
|
2/10/25
|
Givlaari (givosiran) C17924-A – Effective 10/25/24
|
2/10/25
|
Gamifant (emapalumab-lzsg) C15970-A – Effective 10/25/24
|
2/10/25
|
Evkeeza (evinacumab_dgnb) C21101-A – Effective 5/1/24
|
2/10/25
|
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A – Effective 10/25/24
|
2/10/25
|
Enjaymo (sutimlimab) C22996-A - Effective 5/1/24
|
2/10/25
|
Elaprase (idursulfase) C2720-A – Effective 10/25/24
|
2/10/25
|
Cytogam (cytomegalovirus immune globulin) C9970-A – Effective 4/12/24
|
2/10/25
|
Aphexda (motixafortide) C27171-A – Effective 4/12/24
|
2/10/25 |
Leuprolide long acting (Lupron Depot, Eligard, Lupron Depot Ped, Fensolvi, Camcevi) C8756-A - Effective 4/12/24
|
1/10/25 |
MCP 329 Enclosed Bed Systems - Effective 1/7/24
|
1/10/25 |
MCP 293 Spinraza_nusinersen - Effective 10/21/23
|
1/10/25 |
UM CARDIO 1175 Perioperative Cardiovascular Evaluation Before Surgery - Effective 08/24
|
1/8/25 |
Intravenous Bisphosphonates C16790-A - Effective 11/20/23
|
12/31/24 |
MCP 458 Beqvez (fidanacogene elaparvovec-dzkt) - Effective 9/20/24
|
12/21/24 |
Susvimo (ranibizumab) Intravitreal Implant C24231-A – Effective 9/20/24
|
12/16/24
|
Stelara (usketinumab) C10424-A - Effective 1/10/24
|
12/16/24
|
Skyrizi (risankizumab-rzaa) C17336-A - Effective 1/10/24
|
12/16/24
|
Rystiggo (rozanolixizumab) C26210-A – Effective 1/10/24
|
12/16/24
|
Orencia (abatacept) C10420-A - Effective 4/12/24
|
12/16/24
|
Omvoh (mirikizumab) C27293-A - Effective 4/12/24
|
12/16/24
|
NexoBrid (anacaulase-bcdb) C25200-A – Effective 9/21/24
|
12/16/24
|
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A – Effective 5/1/24
|
12/16/24
|
Ilumya (tildrakizumab) C15971-A - Effective 1/14/24
|
12/16/24
|
Ilaris (canakinumab) C2435-A - Effective 1/10/24
|
12/16/24
|
iDose TR (travoprost intracameral implant) C27707-A – Effective 9/20/24
|
12/16/24
|
Durysta (bimatoprost implant) C19830-A – Effective 1/15/24
|
12/16/24
|
Dexycu (dexamethasone intraocular suspension) C16320-A – Effective 9/20/24
|
12/16/24
|
Cosentyx (secukinumab) C10410-A - Effective 5/1/24
|
12/16/24
|
Cinqair (reslizumab) C9761-A – Effective 1/15/24
|
12/16/24
|
Cimzia (certolizumab pegol) C10269-A - Effective 12/16/23
|
12/16/24
|
Calcitonin Gene-Related Peptide (CGRP) Antagonist C15443-C - Effective 11/20/23
|
12/16/24
|
Brineura (cerliponase alfa) C11526-A - Effective 11/16/24
|
12/16/24
|
Beovu (brolucizumab) C17923-A – Effective 1/10/24
|
12/16/24
|
Acthar Gel (repository corticotropin injection) C8373-A – Effective 1/10/24
|
12/16/24 |
MCP 426 Stem Cell Therapy for Orthopedic Applications - Effective 3/6/24
|
12/14/24 |
MCP 235 Measurement of Carotid Artery Intima Thickness – Effective 12/15/23
|
12/14/24
|
MCP 343 Intervertebral Stabilization Devices – Effective 12/15/23
|
12/14/24
|
MCP 352 Dynamic Exoskeletal Orthoses for Lower Extremity Injuries - Effective 3/6/24
|
12/14/24
|
MCP 372 Radiofrequency and Pulsed Radiofrequency for Trigger Point Pain – Effective 1/10/24
|
12/14/24
|
MCP 051 Genetic Testing - Effective 9/20/24
|
12/14/24
|
MCP 389 XEN Gel Stent for Glaucoma - Effective 3/6/24
|
12/14/24
|
MCP 384 Water Vapor Thermal Therapy for BPH - Effective 3/6/24
|
12/14/24
|
MCP 244 Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities – Effective 12/16/23
|
12/14/24
|
MCP 422 Neuromuscular Electrical Training for the Treatment of OSA or Snoring (eXciteOSA) – Effective 3/6/24
|
12/14/24
|
MCP 421 Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Parenteral Nutrition (IPN) – Effective 12/15/23
|
12/14/24
|
MCP 121 Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure – Effective 12/15/23
|
12/14/24
|
MCP 337 Gastroesophageal Reflux Disease GERD Treatment – Effective 12/15/23
|
12/14/24
|
MCP 414 Gastric Electrical Stimulation - Effective 12/15/23
|
12/14/24
|
MCP 443 Fractional Laser Treatment of Traumatic and Burn Scars – Effective 12/16/23
|
12/14/24
|
MCP 145 EPAP for Obstructive Sleep Apnea - Effective 3/6/24
|
12/14/24
|
MCP 347 Autologous Chondrocyte Implantation for Knee – Effective 12/16/23
|
12/14/24
|
MCP 124 3D Interpretation and Reporting of Imaging Studies - Effective 12/16/23
|
12/14/24
|
Ocrevus (ocrelizumab) C11250-A – Effective 9/21/24
|
12/4/24 |
Tezspire(tezepelumab) C23042-A – Effective 1/10/24
|
12/4/24
|
Prolia (denosumab) C8848-A – Effective 10/25/24
|
12/4/24
|
Nucala (mepolizumab) C9704-A – Effective 1/10/24
|
12/4/24
|
Evenity (romosozumab-aqqg) C17324-A – Effective 10/25/24
|
12/4/24
|
Simponi_Simponi Aria (golimumab) C10422-A - Effective 12/16/23
|
12/4/24
|
Hereditary Angioedema Agents C21463-A – Effective 11/19/23
|
11/28/24 |
Enzyme Replacement Therapy for Lysosomal Storage Disorders C9997-A – Effective 11/19/23
|
11/20/24 |
Immunoglobulin (SCIg, IVIg) MHI C21554-A – Effective 11/27/23
|
11/15/24 |
Brineura (cerliponase alfa) C11526-A - Effective 10/21/23
|
11/15/24 |
Adakveo (crizanlizumab-tmca) C17920-A – Effective 11/19/23
|
11/9/24 |
Xolair (omalizumab) C5678-A – Effective 1/10/24
|
11/4/24 |
Testosterone C2270-A – Effective 11/27/23
|
11/4/24
|
Synagis (palivizumab) C6074-A – Effective 12/1/23
|
11/4/24
|
Pulmonary Arterial Hypertension (PAH) C9837-A - Effective 4/12/24
|
11/4/24
|
Hemophilia and Blood Factor Products C15607-A – Effective 11/19/23
|
11/4/24
|
Fasenra (benralizumab) C13643-A - Effective 1/10/24
|
11/4/24
|
Erythropoiesis-stimulating agents (ESAs) C15389-A - Effective 10/21/23
|
11/4/24
|
Entyvio (vedolizumab) C6773-A – Effective 1/10/24
|
11/4/24
|
Actemra (tocilizumab) C10265-A - Effective 12/16/23
|
11/4/24
|
MCP 662 Whole Body MRI and/or CT - Effective 11/13/23
|
11/2/24 |
MCP 442 MISHA Knee Implant System - Effective 10/21/23
|
11/2/24 |
MCP 441 Pancreatic Islet Cell Allotransplantation Lantidra (donislecel-jujn) - Effective 10/21/23
|
11/2/24 |
MCP 440 Pancreatic Islet Cell Transplantation (Autologous) – Effective 11/27/23
|
11/2/24 |
MCP 400 Breyanzi (lisocabtagene maraleucel) - Effective 9/20/24
|
11/2/24 |
MCP 399 Electrostimulation and Electromagnetic Therapy for Wound Care - Effective 11/13/23
|
11/2/24 |
MCP 381 Focused Microwave Thermotherapy for Breast Cancer - Effective 10/21/23
|
11/2/24 |
MCP 377 Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers - Effective 10/21/23
|
11/2/24 |
MCP 368 Transcatheter Tricuspid Valve Repair and Replacement for Tricuspid Valve Disease - Effective 10/21/23
|
11/2/24 |
MCP 366 Cluneal Nerve Block for LBP - Effective 11/13/23
|
11/2/24 |
MCP 357 Skin Substitutes - Effective 9/20/24
|
11/2/24 |
MCP 328 Corneal Collagen Cross Linking - Effective 10/21/23
|
11/2/24 |
MCP 318 Luxturna (voretigene neparvovec rzyl) - Effective 10/21/23
|
11/2/24 |
MCP 308 Visudyne_verteporfin_for Ocular Photodynamic Therapy - Effective 10/21/23
|
11/2/24 |
MCP 250 Prostatic Urethral Lift or UroLift for BPH - Effective 10/21/23
|
11/2/24 |
MCP 181 Radioembolization for Primary and Metastatic Tumors of the Liver - Effective 10/21/23
|
11/2/24 |
MCP 180 QEEG for ADHD with NEBA System - Effective 10/21/23
|
11/2/24 |
MCP 032 Epidural Steroid Injections for Back and Neck Pain - Effective 10/21/23
|
11/2/24 |
Amvuttra (vutrisiran) C24213-A – Effective 11/19/23
|
11/2/24 |
Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A - Effective 11/20/23
|
11/2/24
|
ADZYNMA (ADAMTS13, recombinant-krhn) C27325-A – Effective 4/12/24
|
11/2/24
|
Zoladex (goserelin acetate) C8757-A - Effective 11/20/23
|
10/24/24 |
Vimizim (elosulfase alfa) C7068-A – Effective 11/27/23
|
10/24/24
|
Veopoz (pozelimab-bbfg) C26434-A – Effective 1/10/24
|
10/24/24
|
Uplizna (inebilizumab-cdon) C20171-A – Effective 11/27/23
|
10/24/24
|
Triptodur (triptorelin pamoate) C14649-A - Effective 11/13/23
|
10/24/24
|
Supprelin LA (histrelin acetate) Implant C20611-A – Effective 11/27/23
|
10/24/24
|
Soliris (eculizumab) Ultomiris (ravulizumab) C4867-A C4867-A – Effective 9/21/24
|
10/24/24
|
Signifor (pasireotide diaspartate) C15367-A - Effective 11/13/23
|
10/24/24
|
Ryplazim (plasminogen, human) C22238-A – Effective 11/27/23
|
10/24/24
|
Rolvedon, Neulasta, and Related Biosimilars C10419-A – Effective 3/6/24
|
10/24/24
|
Revcovi (elapegademase) C16329-A - Effective 11/13/23
|
10/24/24
|
Prolia (denosumab) C8848-A – Effective 11/27/23
|
10/24/24
|
Pombiliti (cipaglucosidase alfa) C27242-A – Effective 4/12/24
|
10/24/24
|
Parsabiv (etelcalcetide) C17883-A - Effective 11/13/23
|
10/24/24
|
Oxlumo (lumasiran) C21126-A – Effective 11/27/23
|
10/24/24
|
Onpattro (patisiran)_Tegsedi_(inotersen) C17894-A - Effective 11/13/23
|
10/24/24
|
Nulibry (fosdenopterin) C21306-A – Effective 11/27/23
|
10/24/24
|
Nplate (romiplostim) C6662-A – Effective 11/27/23
|
10/24/24
|
Nexviazyme (alglucosidase alfa-ngpt) C21948-A – Effective 11/27/23
|
10/24/24
|
Mepsevii (vestronidase alfa-vjbk) C17942-A - Effective 11/13/23
|
10/24/24
|
Lumizyme (alglucosidase alfa) C8716_A - Effective 10/21/23
|
10/24/24
|
Korsuva (difelikefalin) C23743-A – Effective 11/27/23
|
10/24/24
|
Kanuma (sebelipase alfa) C9974-A - Effective 11/20/23
|
10/24/24
|
Iron Deficiency Anemia Agents C14569-A - Effective 11/13/23
|
10/24/24
|
Iron Chelating Agents (Desferal, Exjade, Ferriprox, Jadenu) C15214-A - Effective 11/13/23
|
10/24/24
|
Givlaari (givosiran) C17924-A – Effective 11/19/23
|
10/24/24
|
Gamifant (emapalumab-lzsg) C15970-A – Effective 11/19/23
|
10/24/24
|
Filgrastim C2437-A – Effective 11/19/23
|
10/24/24
|
Fabrazyme (agalsidase beta) C4865-A – Effective 11/19/23
|
10/24/24
|
Evenity (romosozumab-aqqg) C17324-A – Effective 11/19/23
|
10/24/24
|
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A – Effective 11/19/23
|
10/24/24
|
Elaprase (idursulfase) C2720-A – Effective 11/19/23
|
10/24/24
|
Crysvita (burosumab-twza) C14517-A - Effective 10/21/23
|
10/24/24
|
UM-2-4000-D Utilization Review Criteria
|
10/3/24 |
Multiple Sclerosis Agents - Interferons C10267-A - Effective 9/11/23
|
9/23/24 |
Copaxone_Glatopa (glatiramer acetate) C10270-A - Effective 9/11/23
|
9/23/24 |
Zinplava (bexlotoxumab) C14821-A - Effective 9/11/23
|
9/20/24 |
Radicava (edaravone) C11528-A - Effective 8/17/23
|
9/20/24 |
Aduhelm (aducanumab-avwa) MNR C21304-A – Effective 1/10/24
|
9/20/24
|
Amondys 45 C21154-A - Effective 11/20/23
|
9/20/24
|
Vyondys 53 (golodirsen) C18466-A - Effective 11/20/23
|
9/20/24
|
Exondys 51 (eteplirsen) C18464-A - Effective 11/20/23
|
9/20/24
|
Ocrevus (ocrelizumab) C11250-A - Effective 9/11/23
|
9/20/24
|
Tysabri (natalizumab) C10276-A - Effective 9/11/23
|
9/20/24
|
Tzield teplizumab C24729-A - Effective 8/17/23
|
9/20/24
|
NexoBrid anacaulase-bcdb C25200-A - Effective 8/17/23
|
9/20/24
|
Leqembi (lecanemab-irmb) C25201-A – Effective 1/10/24
|
9/20/24
|
Briumvi ublituximab-xiiy C25204-A - Effective 10/21/23
|
9/20/24
|
Lemtrada (alemtuzumab) C6919-A - Effective 8/17/23
|
9/20/24
|
Soliris_Ultomiris (eculizumab_ravulizumab) C4867-A – Effective 11/27/23
|
9/20/24
|
Qutenza (capsaicin) C2809-A - Effective 8/17/23
|
9/20/24
|
MCP 667 Xenoview_Xenon MRI - Effective 12/16/23
|
9/19/24
|
MCP 439 Vyjuvek (beremagene geperpavec) - Effective 9/16/23
|
9/19/24
|
MCP 435 OMISIRGE (omidubicel onlv) - Effective 9/16/23
|
9/19/24
|
MCP 432 Developmental Testing - Effective 10/21/23
|
9/19/24
|
MCP 413 Carvykti (ciltacabtagene autoleucel) - Effective 11/13/23
|
9/19/24
|
MCP 403 Abecma (idecabtagene vicleucel) - Effective 11/13/23
|
9/19/24
|
MCP 400 Breyanzi (lisocabtagene maraleucel) - Effective 11/13/23
|
9/19/24
|
MCP 396 Yescarta (axicabtagene ciloleucel) - Effective 11/13/23
|
9/19/24
|
MCP 395 Kymriah (tisagenlecleucel) - Effective 9/16/23
|
9/19/24
|
MCP 378 Tecartus (brexucabtagene autoleucel) - Effective 11/13/23
|
9/19/24
|
MCP 363 Hypoglossal Nerve Stimulation for the Treatment of OSA - Effective 9/16/23
|
9/19/24
|
MCP 357 Skin Substitutes - Effective 7/13/24
|
9/19/24
|
MCP 332 Medically Necessary Services: Policy No. 332 - Effective 7/26/23
|
9/19/24
|
MCP 292 Phototherapy and Laser Therapy for Dermatological Conditions - Effective 7/26/23
|
9/19/24
|
MCP 266 Minimally Invasive Sacroiliac Joint Fusion - Effective 5/1/24
|
9/19/24
|
MCP 257 Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain (RACZ Procedure) - Effective 7/26/23
|
9/19/24
|
MCP 206 Virtual Bronchoscopy for Pulmonary Lesions - Effective 9/16/23
|
9/19/24
|
MCP 205 Functional Electrical Stimulation for Spinal Cord Injury - Effective 7/26/23
|
9/19/24
|
MCP 184 Experimental and Investigational Services - Effective 7/26/23
|
9/19/24
|
MCP 183 Clinical Trials and Rare Disease Policy - Effective 7/26/23
|
9/19/24
|
MCP 051 Genetic Testing - Effective 5/1/24
|
9/19/24
|
MCP 000 Evaluation of New Technology - Effective 9/16/23
|
9/19/24
|
UM CARDIO_1389 Subcutaneous ICD Device Implantation - Effective 3/22/24
|
9/19/24
|
UM CARDIO_1321 Temporal Artery Biopsy - Effective 11/13/23
|
9/19/24
|
UM CARDIO_1291 Coronary Atherectomy - Effective 11/13/23
|
9/19/24
|
UM CARDIO_1257 Device (PPM AICD CRT-D CRT-P Subcut-ICD ILR) Programming - Effective 11/13/23
|
9/19/24
|
UM CARDIO_1256 Device Interrogation - Effective 3/22/24
|
9/19/24
|
UM CARDIO_1255 Lower Extremity Venous Stab Phlebectomy – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1254 Lower Extremity Venous Sclerotherapy – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1253 Lower Extremity Venous Stripping Ligation – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1175 Perioperative Cardiovascular Evaluation Before Surgery – Effective 12/16/23
|
9/19/24
|
UM CARDIO_1168 Inferior Vena Cava Filter Device – Effective 12/16/23
|
9/19/24
|
UM CARDIO_1166 Central Venous Access Procedures – Effective 10/6/23
|
9/19/24
|
UM CARDIO_1149 Cardiac Resynchronization Therapy Implantation – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1147 Pacemaker Implantation – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1145 Pacemaker Battery and Lead(s) Replacement – Effective 10/6/23
|
9/19/24
|
UM CARDIO_1127 Left Heart Catheterization – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1125 Renal_Retroperitoneal Vascular Duplex Ultrasound - Effective 3/22/24
|
9/19/24
|
UM CARDIO_1124 Positron Emission Tomography PET Myocardial Imaging – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1123 Stress Echocardiography – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1122 Transesophageal Echocardiography – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1121 Transthoracic Echocardiography – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1120 Radionuclide Angiogram (MUGA) – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1119 Pharmacological Nuclear Stress Test-Myocardial Perfusion Imaging – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1115 Coronary Computed Tomographic Angiography – Effective 3/22/24
|
9/19/24
|
UM CARDIO 1113 Cardiac Magnetic Resonance Imaging – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1096 Aorta Coronary Bypass Surgery – Effective 10/6/23
|
9/19/24
|
UM CARDIO_1093 Venous Duplex – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1085 Patient Activated Event Recorder – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1083 Vessel Mapping for Hemodialysis Access or CABG Surgery – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1082 Ambulatory EKG Monitoring – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1081 Carotid Duplex – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1080 Automatic Implantable Cardioverter Defibrillator – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1079 Duplex Scan of Hemodialysis Access – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1078 Ankle Brachial Index – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1077 Arterial PVR and Stress Arterial PVR – Effective 3/22/24
|
9/19/24
|
UM CARDIO_1076 Arterial Duplex – Effective 3/22/24
|
9/19/24 |
Kesimpta (ofatumumab) C21104-A – Effective 11/27/23
|
9/17/24 |
MCP 393 Wireless Pulmonary Artery Pressure Monitoring_CardioMEMS_for Congestive Heart Failure - Effective 10/21/23
|
9/5/24 |
UM CARDIO_1084 Myocardial Perfusion Imaging-Exercise Nuclear Stress Testing – Effective 3/22/24
|
9/3/24 |
MCP 438 Adstiladrin_nadofaragene firadenovec vncg - Effective 9/16/23
|
8/31/24
|
MCP 423 Topical and Intralesional Therapies - Effective 9/16/23
|
8/31/24
|
MCP 417 Neutron and Proton Beam Radiation Therapy Policy – Effective 5/1/24
|
8/31/24
|
MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT - Effective 5/1/24
|
8/31/24
|
MCP 415 Pluvicto (lutetium Lu 177 vipivotide tetraxetan) - Effective 9/16/23
|
8/31/24
|
MCP 322 Lutathera (lutetium Lu 177 dotatate) - Effective 11/13/23
|
8/31/24
|
MCP 105 Provenge (sipuleucel-T) – Effective 5/1/24
|
8/31/24
|
Cosela (trilaciclib) C21205-A - Effective 5/1/24
|
8/31/24
|
Adcetris (brentuximab vedotin) C15428-A – Effective 5/1/24
|
8/31/24
|
Octreotide C8839-A – Effective 11/27/23
|
8/31/24 |
Zulresso (brexanolone) C16319-A - Effective 9/11/23
|
8/22/24 |
Cablivi (caplacizumab-yhdp) C19481-A – Effective 11/19/23
|
8/8/24 |
MCP 702 Foot Surgery Lesser Toe Deformities Hammer Mallet and Claw Toe - Effective 9/11/23
|
7/13/24 |
MCP 701 Foot Surgery Hallux Rigidus - Effective 9/11/23
|
7/13/24
|
MCP 700 Foot Surgery Bunionectomy - Effective 9/11/23
|
7/13/24
|
MCP 430 Responsive Neurostimulation for Medically Intractable Focal Epilepsy (NeuroPace®) - Effective 9/11/23
|
7/13/24
|
MCP 412 Prescription Digital Therapeutics - Effective 9/16/23
|
7/13/24
|
MCP 402 Plantar Fasciitis Surgery - Effective 9/16/23
|
7/13/24
|
MCP 397 Moleculight Wound Care Device - Effective 7/26/23
|
7/13/24
|
MCP 385 Peroral Endoscopic Myotomy for Esophageal Achalasia - Effective 7/26/23
|
7/13/24
|
MCP 367 Scenesse (afamelanotide) Implant - Effective 7/26/23
|
7/13/24
|
MCP 361 Renal Autotransplantation - Effective 7/26/23
|
7/13/24
|
MCP 357 Skin Substitutes - Effective 3/6/24
|
7/13/24
|
MCP 333 Steroid-Eluting Sinus Stents and Implants (PROPEL, SINUVA) - Effective 10/6/23
|
7/13/24
|
MCP 315 Breast Implant Removal - Effective 9/16/23
|
7/13/24
|
MCP 222 Interspinous Decompression Devices for Spinal Stenosis - Effective 7/26/23
|
7/13/24
|
MCP 218 Recombinant Human Bone Morphogenetic Protein - Effective 7/26/23
|
7/13/24
|
MCP 207 Platelet Rich Plasma_PRP - Effective 7/26/23
|
7/13/24
|
MCP 204 Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair - Effective 9/16/23
|
7/13/24
|
MCP 161 Robotically Assisted Surgery - Effective 7/26/23
|
7/13/24
|
MCP 120 Transarterial Chemoembolization for Liver Tumors - Effective 7/26/23
|
7/13/24
|
MCP 085 Radiofrequency Ablation for Chronic Back Pain - Effective 7/26/23
|
7/13/24
|
MCP 050 Hyperbaric Oxygen Therapy and Topical Oxygen Therapy - Effective 9/16/23
|
7/13/24
|
MCP 033 Sacroiliac Injections and RFA for SIJ Pain - Effective 7/26/23
|
7/13/24
|
MCP 030 Facet Joint Diagnostic Injections for Chronic Back Pain - Effective 7/26/23
|
7/13/24
|
MCP 411 Susvimo_ranibizumab intravitreal_injection implant - Effective 5/1/24
|
6/27/2024 |
MCP 302 Retisert_Yutiq_fluocinolone acetonide_Intravitreal Implants - Effective 7/13/24
|
6/27/2024 |
MCP 405 Dextenza (dexamethasone intracanalicular insert) - Effective 7/13/24
|
6/19/2024 |
MCP 404 Shoulder Arthroscopy Guidelines - Effective 7/26/23
|
6/19/2024 |
MCP 342 Dexycu (dexamethasone intraocular suspension) - Effective 7/13/24
|
6/19/2024 |
MCP 301 Iluvien (fluocinolone acetonide) Intravitreal Implant – Effective 12/16/23
|
6/19/2024 |
MCP 216a Gender Affirmation Treatment and Procedures_Medicaid - Effective 9/11/23
|
5/28/2024 |
UM-2-4000-10 Endodontic Services - Effective 9/1/23
|
5/24/2024 |
UM-2-4000-9 Other Services - Effective 9/1/23
|
5/24/2024
|
UM-2-4000-8 Anesthesia Services - Effective 11/19/23
|
5/24/2024
|
UM-2-4000-7 Orthodontic Services - Effective 9/1/23
|
5/24/2024
|
UM-2-4000-6 Oral Surgery Services - Effective 9/1/23
|
5/24/2024
|
UM-2-4000-5 Prosthodontic Services - Effective 9/1/23
|
5/24/2024
|
UM-2-4000-4 Periodontic Services - Effective 9/1/23
|
5/24/2024
|
UM-2-4000-3 Restorative Services - Effective 9/1/23
|
5/24/2024
|
UM-2-4000-2 Preventive Services - Effective 9/1/23
|
5/24/2024
|
UM-2-4000-1 Diagnostic Services - Effective 9/1/23
|
5/24/2024
|
MCP 362 Haploididentical Transplantation - Effective 7/26/23
|
5/16/2024 |
MCP 006 Vagal Nerve Stimulation for Epilepsy - Effective 7/26/23
|
4/30/2024 |
MCP 051 Genetic Testing - Effective 9/11/23
|
4/30/2024 |
MCP 105 Provenge (sipuleucel-T) - Effective 9/16/23
|
4/30/2024 |
MCP 133 Ambulatory and Video EEG Monitoring Outpatient Setting - Effective 7/26/23
|
4/30/2024 |
MCP 266 Minimally Invasive Sacroiliac Joint Fusion - Effective 10/21/23
|
4/30/2024 |
MCP 314 Genicular Radiofrequency Ablation RFA and Genicular Nerve Blocks for Chronic Knee Pain - Effective 7/26/23
|
4/30/2024 |
MCP 335 Deep Brain Stimulation DBS for Epilepsy - Effective 9/16/23
|
4/30/2024 |
MCP 338 Plantar Fasciitis Treatment - Effective 7/26/23
|
4/30/2024 |
MCP 339 Interspinous Process Fixation Devices for Spinal Fusion - Effective 7/26/23
|
4/30/2024 |
MCP 340 Implantable Neurostimulator for Central Sleep Apnea - Effective 3/6/24
|
4/30/2024 |
MCP 341 Smart Watch Photoplethysmography (PPG) for Detection of Atrial Fibrillation - Effective 7/26/23
|
4/30/2024 |
MCP 344 Ketogenic Diet for Treatment of Intractable Seizures - Effective 7/26/23
|
4/30/2024 |
MCP 350 MyoPro Orthosis - Effective 7/26/23
|
4/30/2024 |
MCP 353 Electric Tumor Treatment Fields for Glioblastoma - Effective 7/26/23
|
4/30/2024 |
MCP 407 Wound Vac (NPWT) - Effective 9/11/23
|
4/30/2024 |
MCP 410 Genicular Artery Embolization of the Knee for Osteoarthritis - Effective 7/26/23
|
4/30/2024 |
MCP 411 Susvimo_ranibizumab intravitreal_injection implant - Effective 7/26/23
|
4/30/2024 |
MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT - Effective 10/21/23
|
4/30/2024 |
MCP 417 Neutron and Proton Beam Radiation Therapy Policy – Effective 11/19/23
|
4/30/2024 |
MCP 425 Hydrogel Spacer for Prostate Radiotherapy (SpaceOAR) - Effective 8/17/23
|
4/30/2024 |
Cosentyx (secukinumab) C10410-A - Effective 2/3/24
|
4/30/2024 |
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A – Effective 12/16/23
|
4/30/2024 |
Cubicin (daptomycin) C10467-A - Effective 9/11/23
|
4/30/2024 |
Trogarzo (ibalizumab-uiyk) C14522-A - Effective 9/11/23
|
4/30/2024 |
Vibativ (telavancin) C14575-A - Effective 9/11/23
|
4/30/2024 |
Adcetris (brentuximab vedotin) C15428-A - Effective 9/11/23
|
4/30/2024 |
Nuzyra (omadacycline tosylate) C15914-A - Effective 9/11/23
|
4/30/2024 |
Prevymis (letermovir) C15922-A - Effective 9/11/23
|
4/30/2024 |
Standard Oncology Criteria C16154-A - Effective 9/11/23
|
4/30/2024 |
Sexual Dysfunction Criteria - Non-Coverage C16658-A - Effective 9/11/23
|
4/30/2024 |
Reblozyl (luspatercept-aamt) C18002-A – Effective 1/10/24
|
4/30/2024 |
Antiemetics C20780-A – Effective 3/6/24
|
4/30/2024 |
Evkeeza (evinacumab_dgnb) C21101-A – Effective 11/27/23
|
4/30/2024 |
Cosela (trilaciclib) C21205-A - Effective 9/16/23
|
4/30/2024 |
Vabysmo (faricimab) C22795-A – Effective 1/10/24
|
4/30/2024 |
Enjaymo (sutimlimab) C22996-A - Effective 9/11/23
|
4/30/2024 |
Leqvio (inclisiran) C23141-A - Effective 1/10/24
|
4/30/2024 |
Igalmi (dexmedetomidine) C23724-A – Effective 11/19/23
|
4/30/2024 |
MCP 148 Transcatheter Pulmonary Valve Replacement
|
4/26/2024 |
Xacduro (sulbactam and durlobactam) C26432-A – Effective 1/10/24
|
4/22/2024 |
Furoscix (furosemide on-body infusor) C24669– A - Effective 10/6/23
|
4/22/2024
|
MCP 312 Magnetic Resonance Guided Focused Ultrasound_MRgFUS_for Essential Tremor - Effective 9/16/23
|
4/22/2024
|
MCP 011 Artificial Disc Replacement - Effective 7/26/23
|
4/22/2024
|
Orencia (abatacept) C10420-A - Effective 12/16/23
|
4/12/2024
|
Rezzayo (rezafungin) C26183-A - Effective 2/3/24
|
4/12/2024
|
Sunlenca lenacapavir C25206-A - Effective 8/17/23
|
4/12/2024
|
Hepatitis B Immune Globulin C9971-A – Effective 11/19/23
|
4/12/2024
|
Rebyota fecal microbiota live C25213-A - Effective 8/17/23
|
4/12/2024
|
Cytogam (cytomegalovirus immune globulin) C9970-A – Effective 11/19/23
|
4/12/2024
|
Pulmonary Arterial Hypertension (PAH) C9837-A - Effective 10/21/23
|
4/12/2024
|
Sivextro (tedizolid) C9353-A – Effective 11/27/23
|
4/12/2024
|
Dalvance (dalbavancin) C9351-A – Effective 11/19/23
|
4/12/2024
|
Mozobil (plerixafor injection) C9017-A - Effective 8/17/23
|
4/12/2024
|
Leuprolide long acting (Lupron Depot, Eligard, Lupron Depot Ped, Fensolvi, Camcevi) C8756-A - Effective 11/20/23
|
4/12/2024
|
Botulinum Toxin C8755-A - Effective 2/3/24
|
4/12/2024
|
Krystexxa (pegloticase) C2729-A – Effective 2/3/24
|
4/12/2024
|
Leukine (sargramostim) C2439-A - Effective 8/17/23
|
4/12/2024
|
Xgeva (denosumab) C8849-A – Effective 11/27/23
|
4/12/2024 |
MCP 208 Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury - Effective 7/26/23
|
4/10/2024 |
MCP 449 Casgevy (exagamglogene autotemcel) for Beta Thalassemia – Effective 5/1/24
|
4/1/2024 |
MCP 448 Lyfgenia (lovotibeglogene autotemcel) – Effective 5/1/24
|
4/1/2024 |
MCP 447 Casgevy (exagamglogene autotemcel) for Sickle Cell Disease – Effective 5/1/24
|
4/1/2024 |
UM CARDIO_1076 Arterial Duplex Lower Extremities – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1077 Arterial PVR and Stress Arterial PVR – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1078 Ankle Brachial Index – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1079 Duplex Scan of Hemodialysis Access – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1080 Automatic Implantable Cardioverter Defibrillator – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1081 Carotid Duplex – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1082 Ambulatory EKG Monitoring – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1083 Vessel Mapping for Hemodialysis Access or CABG Surgery – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1084 Myocardial Perfusion Imaging-Exercise Nuclear Stress Testing – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1085 Patient Activated Event Recorder – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1093 Venous Duplex – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1094 Percutaneous Coronary Intervention – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1112 Cardiac Telemetry - Effective 11/13/23
|
3/21/2024 |
UM CARDIO 1113 Cardiac Magnetic Resonance Imaging – Effective 1/10/24
|
3/21/2024 |
UM CARDIO_1114 Cardiovascular Stress Test – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1115 Coronary Computed Tomographic Angiography – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1117 Enhanced External Counterpulsation (EECP) – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1119 Pharmacological Nuclear Stress Test-Myocardial Perfusion Imaging – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1120 Radionuclide Angiogram (MUGA) – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1121 Transthoracic Echocardiography – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1122 Transesophageal Echocardiography – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1123 Stress Echocardiography – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1124 Positron Emission Tomography PET Myocardial Imaging – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1125 Renal_Retroperitoneal Vascular Duplex Ultrasound - Effective 10/21/23
|
3/21/2024 |
UM CARDIO_1126 Abdominal Aortic Ultrasound – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1127 Left Heart Catheterization – Effective 10/6/23
|
3/21/2024 |
UM CARDIO 1146 Implantation of Loop Recorder Systems – Effective 1/10/24
|
3/21/2024 |
UM CARDIO_1147 Pacemaker Implantation – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1149 Cardiac Resynchronization Therapy Implantation – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1158 Microvolt T-Wave Alternans - Effective 11/13/23
|
3/21/2024 |
UM CARDIO_1169 Catheter Based Carotid Artery Digital Angio – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1170 Abd Aortography Plus Bilateral Iliofemoral Extremity Runoff – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1171 Carotid Artery Stenting – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1172 Endovascular Iliac Interventions – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1173 Endovascular Femoropopliteal Interventions Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1174 Endovascular Tibioperoneal Interventions – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1252 Endovascular Venous Laser-Radiofrequency Ablation – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1253 Lower Extremity Venous Stripping Ligation – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1254 Lower Extremity Venous Sclerotherapy – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1255 Lower Extremity Venous Stab Phlebectomy – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1256 Device Interrogation - Effective 11/13/23
|
3/21/2024 |
UM CARDIO_1269 Coronary Fractional Flow Reserve - Effective 10/21/23
|
3/21/2024 |
UM CARDIO_1292 Coronary Intra Vascular Arterial Ultrasound - Effective 10/21/23
|
3/21/2024 |
UM CARDIO 1293 Renal Angiography – Effective 1/10/24
|
3/21/2024 |
UM CARDIO_1294 Renal Artery Intervention - Effective 10/21/23
|
3/21/2024 |
UM CARDIO_1295 Trans Catheter Aortic Valve Replacement – Effective 12/16/23
|
3/21/2024 |
UM CARDIO_1296 Trans Catheter Mitral Valve Repair - Effective 10/21/23
|
3/21/2024 |
UM CARDIO_1320 Percutaneous Left Atrial Appendage Closure – Effective 12/16/23
|
3/21/2024 |
UM CARDIO 1336 Automated Ambulatory Blood Pressure Monitoring – Effective 1/10/24
|
3/21/2024 |
UM CARDIO_1339 Hemodialysis Access Maintenance - Effective 10/21/23
|
3/21/2024 |
UM CARDIO_1368 Percutaneous IlioCaval Intervention – Effective 10/6/23
|
3/21/2024 |
UM CARDIO_1389 Subcutaneous ICD Device Implantation - Effective 10/21/23
|
3/21/2024 |
UM CARDIO_1390 Ventricular Assist Device (VAD) Percutaneous and Permanent – Effective 10/6/23
|
3/21/2024 |
MCP 132 Percutaneous Ventricular Assist Devices - Effective 3/1/23
|
3/15/2024 |
MCP 427 Microwave Tumor Ablation - Effective 3/1/23
|
3/6/2024 |
MCP 426 Stem Cell Therapy for Orthopedic Applications - Effective 3/1/23
|
3/6/2024
|
MCP 422 Neuromuscular Electrical Training for the Treatment of OSA or Snoring (eXciteOSA) – Effective 12/16/23
|
3/6/2024
|
MCP 408 Balloon Sinus Ostial Dilation_Balloon Sinuplasty - Effective 3/1/23
|
3/6/2024
|
MCP 389 XEN Gel Stent for Glaucoma - Effective 3/1/23
|
3/6/2024
|
MCP 386 Coolief Cooled Radiofrequency - Effective 3/1/23
|
3/6/2024
|
MCP 384 Water Vapor Thermal Therapy for BPH - Effective 3/1/23
|
3/6/2024
|
MCP 383 IB-Stim Device for Abdominal Pain in Adolescents - Effective 3/1/23
|
3/6/2024
|
MCP 357 Skin Substitutes - Effective 9/16/23
|
3/6/2024
|
MCP 352 IDEO Intrepid Dynamic Exoskeletal Orthosis - Effective 3/1/23
|
3/6/2024
|
MCP 351 MILD for Spinal Stenosis - Effective 3/1/23
|
3/6/2024
|
MCP 340 Implantable Neurostimulator for Central Sleep Apnea - Effective 3/1/23
|
3/6/2024
|
MCP 321 Category III CPT Codes - Effective 3/1/23
|
3/6/2024
|
MCP 145 EPAP for Obstructive Sleep Apnea - Effective 3/1/23
|
3/6/2024
|
Rolvedon, Neulasta and Related Biosimilars C10419-A - Effective 9/11/23
|
3/6/2024
|
Antiemetics C20780-A – Effective 10/6/23
|
3/6/2024
|
Zyvox (linezolid), linezolid C8632– A - Effective 10/6/23
|
3/4/2024 |
Veklury (remdesivir) C20763-A – Effective 11/27/23
|
3/4/2024
|
Mycamine (micafungin) C9347-A – Effective 11/27/23
|
3/4/2024
|
Cancidas (caspofungin) C17928-A - Effective 9/11/23
|
3/4/2024
|
Azactam (aztreonam) C10143-A - Effective 9/11/23
|
3/4/2024
|
Tygacil (tigecycline) C14555-A - Effective 11/13/23
|
2/15/2024 |
Fuzeon (enfuvirtide) C9573– A - Effective 10/6/23
|
2/15/2024 |
Botulinum Toxin C8755-A - Effective 1/14/24
|
2/2/2024 |
Krystexxa (pegloticase) C2729-A – Effective 11/27/23
|
2/2/2024 |
Cosentyx (secukinumab) C10410-A - Effective 10/21/23
|
2/2/2024 |
MCP 282 Ozurdex (dexamethasone intravitreal implant) - Effective 7/26/23
|
2/2/2024 |
Cinqair (reslizumab) C9761-A – Effective 11/19/23
|
1/15/2024 |
Nulojix (belatacept) C9968-A – Effective 11/27/23
|
1/15/2024 |
Xipere (triamcinolone ocular inj) C22222-A – Effective 11/27/23
|
1/15/2024 |
MCP 370 Durysta (bimatoprost) Implant - Effective 7/26/23
|
1/14/2024 |
Syfovre (pegcetacoplan) C25311-A - Effective 11/26/23
|
1/14/2024 |
Ilumya (tildrakizumab) C15971-A - Effective 11/20/23
|
1/14/2024 |
Botulinum Toxin C8755-A - Effective 3/1/23
|
1/14/2024 |
UM CARDIO_1143 Non Invasive Programmed Stimulation of AICD_11282022 – Effective 3/1/23
|
1/10/24 |
UM CARDIO_1146 Implantation of Loop Recorder Systems – Effective 10/6/23
|
1/10/24 |
UM CARDIO_1268 Aorto-Renal Endarterectomy or Bypass Surgery_09302022
|
1/10/24 |
UM CARDIO_1293 Renal Angiography – Effective 10/6/23
|
1/10/24 |
UM CARDIO_1336 Automated Ambulatory Blood Pressure Monitoring_11282022 – Effective 3/1/23
|
1/10/24 |
UM CARDIO_1453 Ultrasound Guided Vascular Access - Effective 10/21/23
|
1/10/24 |
UM CARDIO_1113 Cardiac Magnetic Resonance Imaging_11282022 – Effective 3/1/23
|
1/10/24 |
Leqvio (inclisiran) C23141-A - Effective 12/7/23
|
1/10/24 |
Xolair (omalizumab) C5678-A - Effective 8/17/23
|
1/10/24 |
Vyvgart (efgartigimod alfa) C23127-A – Effective 3/1/23
|
1/10/24 |
Vabysmo (faricimab) C22795-A – Effective 3/1/23
|
1/10/24 |
Tezspire(tezepelumab) C23042-A – Effective 3/1/23
|
1/10/24 |
Tepezza (teprotumumab-trbw) C18462-A – Effective 11/27/23
|
1/10/24 |
Skyrizi (risankizumab-rzaa) C17336-A - Effective 11/13/23
|
1/10/24 |
Saphnelo (anifrolumab) C21970-A – Effective 11/27/23
|
1/10/24 |
Reblozyl (luspatercept-aamt) C18002-A - Effective 9/11/23
|
1/10/24 |
Acthar Gel (repository corticotropin injection) C8373-A – Effective 3/1/23
|
1/10/24 |
Benlysta (belimumab) C2722-A – Effective 11/19/23
|
1/10/24 |
Beovu (brolucizumab) C17923-A
|
1/10/24 |
Aduhelm (aducanumab-avwa) Medical Necessity Review C21304-A - Effective 9/11/23
|
1/10/24 |
Entyvio (vedolizumab) C6773-A – Effective 11/19/23
|
1/10/24 |
Eylea (aflibercept) C5674-A - Effective 8/17/23
|
1/10/24 |
Ilaris (canakinumab) C2435-A - Effective 11/20/23
|
1/10/24 |
Hyaluronic Acid Injections_Viscosupplementation for Knee OA C14676-A - Effective 10/21/23
|
1/10/24 |
Leqembi (lecanemab-irmb) MNR C25201-A - Effective 8/17/23
|
1/10/24 |
Stelara (usketinumab) C10424-A - Effective 11/13/23
|
1/10/24 |
Fasenra (benralizumab) C13643-A - Effective 10/21/23
|
1/10/24 |
Nucala (mepolizumab) C9704-A – Effective 11/27/23
|
1/10/24 |
Rituxan (rituximab) and Biosimilars C10423-A - Effective 11/13/23
|
1/10/24 |
MCP 372 Radiofrequency and Pulsed Radiofrequency for Trigger Point Pain
|
1/10/24 |
MCP 428 Mobile Cardiac Outpatient Telemetry
|
1/8/2024 |
Physician Administered Drugs C11251-A - Effective 9/11/23
|
1/7/2024 |
MCP 329 Enclosed Bed Systems - Effective 3/1/23
|
1/7/2024 |
MCP 392 Monarch External Trigeminal Nerve Stimulation eTNS System
|
1/4/2024 |
MCP 391 Radiofrequency Ablation of Primary or Metastatic Liver Tumors
|
1/1/2024 |
MCP 433 Roctavian (valoctocogene roxaparvovec) - Effective 10/21/23
|
1/1/2024 |
MCP 124 3D Interpretation and Reporting of Imaging Studies - Effective 9/16/23
|
12/15/2023
|
MCP 347 Autologous Chondrocyte Implantation for Knee
|
12/15/2023
|
MCP 301 Iluvien (fluocinolone acetonide) Intravitreal Implant
|
12/15/2023
|
MCP 244 Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities
|
12/15/2023
|
MCP 422 Neuromuscular Electrical Training for the Treatment of OSA or Snoring (eXciteOSA)
|
12/15/2023
|
MCP 667 Xenoview_Xenon MRI - Effective 9/16/23
|
12/15/2023
|
UM CARDIO_1095 Aortic Valve Replacement_09302022
|
12/15/2023
|
UM CARDIO_1097 Ascending Aortic Graft Surgery_10282022
|
12/15/2023
|
UM CARDIO_1098 Descending Thoracic Aortic Graft Surgery_09302022
|
12/15/2023
|
UM CARDIO_1100 Tricuspid Valve Surgery_09302022
|
12/15/2023
|
UM CARDIO_1139 Electrophysiology Study with Arrhythmia Induction_09302022
|
12/15/2023
|
UM CARDIO_1152 Device Physiologic CV Data Element Interrogation_10282022
|
12/15/2023
|
UM CARDIO_1162 Endo Vascular Abdominal Aortic and Iliac Artery Aneurysm Repair_09302022
|
12/15/2023
|
UM CARDIO_1163 Carotid Endarterectomy_09302022
|
12/15/2023
|
UM CARDIO_1168 Inferior Vena Cava Filter Device_09302022
|
12/15/2023
|
UM CARDIO_1175 Perioperative Cardiovascular Evaluation Before Surgery_10282022
|
12/15/2023
|
UM CARDIO_1295 Trans Catheter Aortic Valve Replacement_09302022
|
12/15/2023
|
UM CARDIO_1320 Percutaneous Left Atrial Appendage Closure_09302022
|
12/15/2023
|
UM CARDIO_1337 Abdominal Aortic Aneurysm Open Repair_09302022
|
12/15/2023
|
UM CARDIO_1417 Percutaneous Closure of PFO_10282022
|
12/15/2023
|
Actemra (tocilizumab) C10265-A - Effective 10/21/23
|
12/15/2023
|
Cimzia (certolizumab pegol) C10269-A - Effective 10/21/23
|
12/15/2023
|
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A
|
12/15/2023
|
UM CARDIO_1370 Thoracentesis and Pleurodesis_09302022
|
12/15/2023
|
Orencia (abatacept) C10420-A - Effective 11/13/23
|
12/15/2023
|
Ranibizumab (Lucentis, Byooviz, Cimerli) MHI C10417-A – Effective 3/1/23
|
12/15/2023
|
Simponi_Simponi Aria (golimumab) C10422-A - Effective 11/13/23
|
12/15/2023
|
MCP 421 Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Parenteral Nutrition (IPN) – Effective 3/1/23
|
12/14/2023
|
MCP 414 Gastric Electrical Stimulation - Effective 9/11/23
|
12/14/2023
|
MCP 343 Intervertebral Stabilization Devices – Effective 3/1/23
|
12/14/2023
|
MCP 337 Gastroesophageal Reflux Disease GERD Treatment – Effective 3/1/23
|
12/14/2023
|
MCP 235 Measurement of Carotid Artery Intima Thickness – Effective 3/1/23
|
12/14/2023
|
MCP 121 Inhaled Nitric Oxide iNO for Neonatal Hypoxic Respiratory Failure – Effective 3/1/23
|
12/14/2023
|
Leqvio (inclisiran) C23141-A - Effective 3/1/23
|
12/6/2023
|
Synagis (palivizumab) C6074-A – Effective 11/27/23
|
11/30/2023
|
Xgeva (denosumab) C8849-A
|
11/26/2023
|
Korsuva (difelikefalin) C23743-A
|
11/26/2023
|
Krystexxa (pegloticase) C2729-A
|
11/26/2023
|
Soliris_Ultomiris (eculizumab_ravulizumab) C4867-A
|
11/26/2023
|
Nplate (romiplostim) C6662-A
|
11/26/2023
|
Vimizim (elosulfase alfa) C7068-A
|
11/26/2023
|
Octreotide C8839-A
|
11/26/2023
|
Prolia (denosumab) C8848-A
|
11/26/2023
|
Mycamine (micafungin) C9347-A
|
11/26/2023
|
Sivextro (tedizolid) C9353-A
|
11/26/2023
|
Nucala (mepolizumab) C9704-A
|
11/26/2023
|
Nulojix (belatacept) C9968-A
|
11/26/2023
|
MCP 440 Pancreatic Islet Cell Transplantation - Effective 9/16/23
|
11/26/2023
|
Synagis (palivizumab) C6074-A
|
11/26/2023
|
Tepezza (teprotumumab-trbw) C18462-A
|
11/26/2023
|
Uplizna (inebilizumab-cdon) C20171-A
|
11/26/2023
|
Supprelin LA (histrelin acetate) Implant C20611-A
|
11/26/2023
|
Veklury (remdesivir) C20763-A
|
11/26/2023
|
Evkeeza (evinacumab_dgnb) C21101-A
|
11/26/2023
|
Kesimpta (ofatumumab) C21104-A
|
11/26/2023
|
Oxlumo (lumasiran) C21126-A
|
11/26/2023
|
Nulibry (fosdenopterin) C21306-A
|
11/26/2023
|
Immunoglobulin (SCIg, IVIg) MHI C21554-A
|
11/26/2023
|
Nexviazyme (alglucosidase alfa-ngpt) C21948-A
|
11/26/2023
|
Saphnelo (anifrolumab) C21970-A
|
11/26/2023
|
Xipere (triamcinolone ocular inj) C22222-A
|
11/26/2023
|
Ryplazim (plasminogen, human) C22238-A
|
11/26/2023
|
Testosterone C2270-A
|
11/26/2023
|
Zoladex (goserelin acetate) C8757-A - Effective 3/1/23
|
11/19/2023
|
Vyondys 53 (golodirsen) Medical Necessity Review C18466-A - Effective 3/1/23
|
11/19/2023
|
Leuprolide long acting (Lupron Depot, Eligard, Lupron Depot Ped, Fensolvi, Camcevi) C8756-A - Effective 3/1/23
|
11/19/2023
|
Kanuma (sebelipase alfa) C9974-A - Effective 3/1/23
|
11/19/2023
|
Intravenous Bisphosphonates C16790-A - Effective 3/1/23
|
11/19/2023
|
Ilumya (tildrakizumab) C15971-A - Effective 3/1/23
|
11/19/2023
|
Ilaris (canakinumab) C2435-A - Effective 3/1/23
|
11/19/2023 |
Exondys 51 (eteplirsen) Medical Necessity Review C18464-A - Effective 9/11/23
|
11/19/2023
|
Calcitonin Gene-Related Peptide (CGRP) antagonist C15443-C - Effective 9/16/23
|
11/19/2023
|
Amondys 45 (casimersen) Medical Necessity Review C21154-A - Effective 9/11/23
|
11/19/2023
|
Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A - Effective 3/1/23
|
11/19/2023 |
Hepatitis B Immune Globulin C9971-A – Effective 3/1/23
|
11/18/2023 |
Igalmi (dexmedetomidine) C23724-A – Effective 3/1/23
|
11/18/2023 |
Hereditary Angioedema Agents C21463-A – Effective 3/1/23
|
11/18/2023 |
Enzyme Replacement Therapy for Lysosomal Storage Disorders C9997-A – Effective 3/1/23
|
11/18/2023 |
Cytogam (cytomegalovirus immune globulin) C9970-A – Effective 3/1/23
|
11/18/2023 |
Cinqair (reslizumab) C9761-A – Effective 3/1/23
|
11/18/2023 |
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A – Effective 3/1/23
|
11/18/2023 |
Dalvance (dalbavancin) C9351-A – Effective 3/1/23
|
11/18/2023 |
Entyvio (vedolizumab) C6773-A – Effective 3/1/23
|
11/18/2023 |
Fabrazyme (agalsidase beta) C4865-A – Effective 3/1/23
|
11/18/2023 |
Benlysta (belimumab) C2722-A – Effective 3/1/23
|
11/18/2023 |
Elaprase (idursulfase) C2720-A – Effective 3/1/23
|
11/18/2023 |
Filgrastim C2437-A – Effective 3/1/23
|
11/18/2023 |
Amvuttra (vutrisiran) C24213-A – Effective 3/1/23
|
11/18/2023 |
Cablivi (caplacizumab-yhdp) C19481-A – Effective 3/1/23
|
11/18/2023 |
Givlaari (givosiran) C17924-A – Effective 3/1/23
|
11/18/2023 |
Adakveo (crizanlizumab-tmca) C17920-A – Effective 3/1/23
|
11/18/2023 |
Evenity (romosozumab-aqqg) C17324-A – Effective 3/1/23
|
11/18/2023 |
Gamifant (emapalumab-lzsg) C15970-A – Effective 3/1/23
|
11/18/2023 |
Hemophilia and Blood Factor Products C15607-A – Effective 3/1/23
|
11/18/2023 |
UM-2-4000-8 Anesthesia Services - Effective 9/1/23
|
11/18/2023 |
MCP 417 Neutron and Proton Beam Radiation Therapy Policy – Effective 3/1/23
|
11/18/2023 |
MCP 662 Whole Body MRI - Effective 7/26/23
|
11/12/2023
|
MCP 413 Carvykti (ciltacabtagene autoleucel) - Effective 3/1/23
|
11/12/2023
|
MCP 403 Abecma (idecabtagene vicleucel) - Effective 3/1/23
|
11/12/2023
|
MCP 400 Breyanzi (lisocabtagene maraleucel) - Effective 3/1/23
|
11/12/2023
|
MCP 399 Electrostimulation and Electromagnetic Therapy for Wound Care - Effective 3/1/23
|
11/12/2023
|
MCP 396 Yescarta (axicabtagene ciloleucel) - Effective 3/1/23
|
11/12/2023
|
MCP 378 Tecartus (brexucabtagene autoleucel) - Effective 3/1/23
|
11/12/2023
|
MCP 322 Lutathera (lutetium Lu 177 dotatate) - Effective 3/1/23
|
11/12/2023
|
MCP 366 Cluneal Nerve Block for LBP - Effective 3/1/23
|
11/12/2023
|
UM CARDIO_1418 Intervention on Adults with Congenital Heart Defects_07292022
|
11/12/2023
|
UM CARDIO_1358 Intra Cardiac Echocardiography_07292022
|
11/12/2023
|
UM CARDIO_1321 Temporal Artery Biopsy_07292022
|
11/12/2023
|
UM CARDIO_1318 Peripheral Arterial and Venous Ultrasound_07292022
|
11/12/2023
|
UM CARDIO_1291 Coronary Atherectomy_08262022
|
11/12/2023
|
UM CARDIO_1257 Device (PPM AICD CRT-D CRT-P Subcut-ICD ILR) Programming_07292022
|
11/12/2023
|
UM CARDIO_1256 Device Interrogation_07292022
|
11/12/2023
|
UM CARDIO_1159 Tilt Table Testing_07292022
|
11/12/2023
|
UM CARDIO_1158 Microvolt T-Wave Alternans_07292022
|
11/12/2023
|
UM CARDIO_1112 Cardiac Telemetry_07292022
|
11/12/2023
|
Tygacil (tigecycline) C14555-A - Effective 3/1/23
|
11/12/2023
|
Triptodur (triptorelin pamoate) C14649-A - Effective 3/1/23
|
11/12/2023
|
Stelara (usketinumab) C10424-A - Effective 3/1/23
|
11/12/2023
|
Skyrizi (risankizumab-rzaa) C17336-A - Effective 3/1/23
|
11/12/2023
|
Simponi_Simponi Aria (golimumab) C10422-A - Effective 3/1/23
|
11/12/2023
|
Signifor (pasireotide diaspartate) C15367-A - Effective 3/1/23
|
11/12/2023
|
Rituxan (rituximab) and Biosimilars C10423-A - Effective 3/1/23
|
11/12/2023
|
Revcovi (elapegademase) C16329-A - Effective 3/1/23
|
11/12/2023
|
Parsabiv (etelcalcetide) C17883-A - Effective 3/1/23
|
11/12/2023
|
Orencia (abatacept) C10420-A - Effective 3/1/23
|
11/12/2023
|
Onpattro (patisiran)_Tegsedi_(inotersen) C17894-A - Effective 3/1/23
|
11/12/2023
|
Mepsevii (vestronidase alfa-vjbk) C17942-A - Effective 3/1/23
|
11/12/2023
|
Iron Deficiency Anemia Agents C14569-A - Effective 3/1/23
|
11/12/2023
|
Iron Chelating Agents (Desferal, Exjade, Ferriprox, Jadenu) C15214-A - Effective 3/1/23
|
11/12/2023 |
| MCP 429 Hemgenix (etranacogene dezaparvovec-drlb) - Effective 9/16/23 |
11/8/2023 |
| UM CARDIO_1427 Cardiac Surveillance Following COVID-19 Infection - Effective 10/21/23 |
11/8/2023 |
MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT - Effective 9/16/23
|
10/20/2023
|
MCP 393 Wireless Pulmonary Artery Pressure Monitoring_CardioMEMS_for Congestive Heart Failure - Effective 3/1/23
|
10/20/2023
|
MCP 381 Focused Microwave Thermotherapy for Breast Cancer - Effective 3/1/23
|
10/20/2023
|
MCP 377 Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers - Effective 3/1/23
|
10/20/2023
|
MCP 368 Transcatheter Tricuspid Valve Replacement - Effective 3/1/23
|
10/20/2023
|
MCP 328 Corneal Collagen Cross Linking - Effective 3/1/23
|
10/20/2023
|
MCP 318 Luxturna (voretigene neparvovec rzyl) - Effective 3/1/23
|
10/20/2023
|
MCP 266 Minimally Invasive Sacroiliac Joint Fusion - Effective 7/26/23
|
10/20/2023
|
MCP 308 Visudyne_verteporfin_for Ocular Photodynamic Therapy - Effective 3/1/23
|
10/20/2023
|
MCP 293 Spinraza_nusinersen - Effective 3/1/23
|
10/20/2023
|
MCP 250 Prostatic Urethral Lift or UroLift for BPH - Effective 3/1/23
|
10/20/2023
|
MCP 181 Radioembolization for Primary and Metastatic Tumors of the Liver - Effective 3/1/23
|
10/20/2023
|
MCP 180 QEEG for ADHD with NEBA System - Effective 3/1/23
|
10/20/2023
|
MCP 032 Epidural Steroid Injections for Back and Neck Pain - Effective 3/1/23
|
10/20/2023
|
Erythropoiesis-stimulating agents (ESAs) C15389-A - Effective 3/1/23
|
10/20/2023
|
Hyaluronic Acid Injections_Viscosupplementation for Knee OA C14676-A - Effective 3/1/23
|
10/20/2023
|
Crysvita (burosumab-twza) C14517-A - Effective 3/1/23
|
10/20/2023
|
Fasenra (benralizumab) C13643-A - Effective 3/1/23
|
10/20/2023
|
Brineura (cerliponase alfa) C11526-A - Effective 3/1/23
|
10/20/2023
|
Cosentyx (secukinumab) C10410-A - Effective 3/1/23
|
10/20/2023
|
Cimzia (certolizumab pegol) C10269-A - Effective 3/1/23
|
10/20/2023
|
Actemra (tocilizumab) C10265-A - Effective 3/1/23
|
10/20/2023
|
Pulmonary Arterial Hypertension (PAH) C9837-A - Effective 3/1/23
|
10/20/2023
|
Briumvi ublituximab-xiiy C25204-A - Effective 8/17/23
|
10/20/2023
|
Lumizyme (alglucosidase alfa) C8716_A - Effective 3/1/23
|
10/20/2023
|
UM CARDIO_1453 Ultrasound Guided Vascular Access_12312021
|
10/20/2023
|
UM CARDIO_1427 Cardiac Surveillance Following COVID-19 Infection_03252022
|
10/20/2023
|
UM CARDIO_1402 Wireless Pulmonary Artery Pressure Device Policy_08262022
|
10/20/2023
|
UM CARDIO_1389 Subcutaneous ICD Device Implantation_07292022
|
10/20/2023
|
UM CARDIO_1339 Hemodialysis Access Maintenance_01282022
|
10/20/2023
|
UM CARDIO_1319 Venogram Invasive Vein Mapping_03252022
|
10/20/2023
|
UM CARDIO_1296 Trans Catheter Mitral Valve Repair_09302022
|
10/20/2023
|
UM CARDIO_1294 Renal Artery Intervention_07292022
|
10/20/2023
|
UM CARDIO_1292 Coronary Intra Vascular Arterial Ultrasound_07292022
|
10/20/2023
|
UM CARDIO_1269 Coronary Fractional Flow Reserve_07292022
|
10/20/2023
|
UM CARDIO_1125 Renal_Retroperitoneal Vascular Duplex Ultrasound_12312021
|
10/20/2023 |
INPEN (Insulin Smart Pen) Non-Coverage C21865-A
|
10/19/2023 |
| MCP 134 Therapeutic Apheresis |
10/12/2023
|
| MCP 234 Bioimpedence Analysis for Lymphedema Assessment |
10/12/2023
|
| MCP 243 Gastrointestinal Electrical Stimulation GES for Obesity |
10/12/2023
|
| Linezolid C8632-A |
10/6/2023 |
UM CARDIO_1456 Vascular Embolization and Occlusion_01282022
|
10/5/2023 |
UM CARDIO_1390 Ventricular Assist Device (VAD) Percutaneous and Permanent_01282022
|
10/5/2023
|
UM CARDIO_1388 Endomyocardial Biopsy_01282022
|
10/5/2023 |
UM CARDIO_1369 Pericardial Disease Interventions_01282022
|
10/5/2023 |
UM CARDIO_1368 Percutaneous IlioCaval Intervention_01282022
|
10/5/2023 |
UM CARDIO_1293 Renal Angiography_12312021
|
10/5/2023
|
UM CARDIO_1255 Lower Extremity Venous Stab Phlebectomy_04292022
|
10/5/2023 |
UM CARDIO_1254 Lower Extremity Venous Sclerotherapy_04292022
|
10/5/2023 |
UM CARDIO_1253 Lower Extremity Venous Stripping Ligation_07292022
|
10/5/2023 |
UM CARDIO_1252 Endovascular Venous Laser-Radiofrequency Ablation_04292022
|
10/5/2023 |
UM CARDIO_1174 Endovascular Tibioperoneal Interventions_10282022
|
10/5/2023 |
UM CARDIO_1173 Endovascular Femoropopliteal Interventions_09302022
|
10/5/2023 |
UM CARDIO_1172 Endovascular Iliac Interventions_10282022
|
10/5/2023 |
UM CARDIO_1171 Carotid Artery Stenting_01282022
|
10/5/2023 |
UM CARDIO_1170 Abd Aortography Plus Bilateral Iliofemoral Extremity Runoff_10282022
|
10/5/2023 |
UM CARDIO_1169 Catheter Based Carotid Artery Digital Angio_01282022
|
10/5/2023 |
UM CARDIO_1166 Central Venous Access Procedures_11282022
|
10/5/2023 |
UM CARDIO_1165 Hemodialysis Access Creation_02252022
|
10/5/2023 |
UM CARDIO_1164 Femoral Popliteal Bypass Surgery_03252022
|
10/5/2023 |
UM CARDIO_1149 Cardiac Resynchronization Therapy Implantation_07292022
|
10/5/2023 |
UM CARDIO_1148 Synchronized Electrical Cardioversion_01282022
|
10/5/2023 |
UM CARDIO_1147 Pacemaker Implantation_01282022
|
10/5/2023 |
UM CARDIO_1146 Implantation of Loop Recorder Systems_02252022
|
10/5/2023 |
UM CARDIO_1145 Pacemaker Battery and Lead(s) Replacement_07292022
|
10/5/2023 |
UM CARDIO_1144 Defibrillator Battery Replacement_02252022
|
10/5/2023 |
UM CARDIO_1142 EPS with AI and AFib AVN and AP Ablation_07292022
|
10/5/2023 |
UM CARDIO_1141 EPS with AI_Pacing after DI and Atrial or SVT and AP Ablation_07292022
|
10/5/2023 |
UM CARDIO_1140 EPS with Transseptal Left Heart Cath with Arrhythmia Induction and VT Ablation_07292022
|
10/5/2023 |
UM CARDIO_1127 Diagnostic Heart Catheterization_02252022
|
10/5/2023 |
UM CARDIO_1126 Abdominal Aortic Ultrasound_08262022
|
10/5/2023 |
UM CARDIO_1124 Positron Emission Tomography PET Myocardial Imaging_07292022
|
10/5/2023 |
UM CARDIO_1123 Stress Echocardiography_07292022
|
10/5/2023 |
UM CARDIO_1122 Transesophageal Echocardiography_02252022
|
10/5/2023 |
UM CARDIO_1121 Transthoracic Echocardiography_03252022
|
10/5/2023 |
UM CARDIO_1120 Radionuclide Angiogram (MUGA)_07292022
|
10/5/2023 |
UM CARDIO_1119 Pharmacological Nuclear Stress Test-Myocardial Perfusion Imaging_07292022
|
10/5/2023 |
UM CARDIO_1117 Enhanced External Counterpulsation (EECP)_01282022
|
10/5/2023 |
UM CARDIO_1115 Coronary Computed Tomographic Angiography_09302022
|
10/5/2023 |
UM CARDIO_1114 Cardiovascular Stress Test_09302022
|
10/5/2023 |
UM CARDIO_1101 Cardiac Electrophysiology Study without Arrhythmia Induction_07292022
|
10/5/2023 |
UM CARDIO_1099 Mitral Valve Surgery_09302022
|
10/5/2023 |
UM CARDIO_1096 Aorta Coronary Bypass Surgery_10282022
|
10/5/2023 |
UM CARDIO_1094 Percutaneous Coronary Intervention_10282022
|
10/5/2023 |
UM CARDIO_1093 Venous Duplex_07292022
|
10/5/2023 |
UM CARDIO_1085 Patient Activated Event Recorder_07292022
|
10/5/2023 |
UM CARDIO_1084 Myocardial Perfusion Imaging-Exercise Nuclear Stress Testing_07292022
|
10/5/2023 |
UM CARDIO_1083 Vessel Mapping for Hemodialysis Access or CABG Surgery_11282022
|
10/5/2023 |
UM CARDIO_1082 Ambulatory EKG Monitoring_07292022
|
10/5/2023 |
UM CARDIO_1081 Carotid Duplex_02252022
|
10/5/2023 |
UM CARDIO_1080 Automatic Implantable Cardioverter Defibrillator_10282022
|
10/5/2023 |
UM CARDIO_1079 Duplex Scan of Hemodialysis Access_07292022
|
10/5/2023 |
UM CARDIO_1078 Ankle Brachial Index_02252022
|
10/5/2023 |
UM CARDIO_1077 Arterial PVR and Stress Arterial PVR_07292022
|
10/5/2023
|
UM CARDIO_1076 Arterial Duplex)-7292022
|
10/5/2023 |
MCP 333 Steroid-Eluting Sinus Stents and Implants (PROPEL, SINUVA) - Effective 7/26/23
|
10/5/2023 |
Antiemetics C20780-A – Effective 3/1/23
|
10/5/2023 |
Cosela (trilaciclib) C21205-A - Effective 3/1/23
|
9/15/2023 |
Calcitonin Gene-Related Peptide (CGRP) Antagonist C15443-C - Effective 3/1/23
|
9/15/2023 |
MCP 423 Topical and Intralesional Therapies - Effective 3/1/23
|
9/15/2023 |
| MCP 416 External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT - Effective 3/1/23 |
9/15/2023 |
MCP 415 Pluvicto (lutetium Lu 177 vipivotide tetraxetan) - Effective 3/1/23
|
9/15/2023 |
MCP 412 Prescription Digital Therapeutics - Effective 3/1/23
|
9/15/2023 |
| MCP 402 Plantar Fasciitis Surgery - Effective 3/1/23 |
9/15/2023 |
MCP 395 Kymriah (tisagenlecleucel) - Effective 3/1/23
|
9/15/2023 |
MCP 363 Hypoglossal Nerve Stimulation for OSA - Effective 3/1/23
|
9/15/2023 |
MCP 357 Skin Substitutes for Chronic Wound Healing Outpatient - Effective 3/1/23
|
9/15/2023 |
MCP 335 Deep Brain Stimulation DBS for Epilepsy - Effective 3/1/23
|
9/15/2023 |
MCP 315 Breast Implant Removal - Effective 3/1/23
|
9/15/2023 |
| MCP 312 Magnetic Resonance Guided Focused Ultrasound (MRgFUS) for Essential Tremor - Effective 3/1/23 |
9/15/2023 |
| MCP 206 Virtual Bronchoscopy for Pulmonary Lesions - Effective 3/1/23 |
9/15/2023 |
| MCP 204 Blepharoplasty - Effective 3/1/23 |
9/15/2023 |
| MCP 124 3D Interpretation and Reporting of Imaging Studies - Effective 3/1/23 |
9/15/2023 |
MCP 105 Provenge (sipuleucel-T) - Effective 3/1/23
|
9/15/2023 |
MCP 050 Hyperbaric Oxygen Therapy and Topical Oxygen Therapy - Effective 3/1/23
|
9/15/2023 |
MCP 000 Evaluation of New Technology - Effective 3/1/23
|
9/15/2023 |
| MCP 127 Thermography and BSGI Imaging for the Detection of Breast Lesions |
9/15/2023 |
| MCP 371 Myocardial Strain Imaging |
9/15/2023 |
| MCP 374 Actigraphy |
9/15/2023 |
| MCP 382 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders |
9/15/2023 |
Pegfilgrastim C10419-A
|
9/11/2023 |
Global J Code Criteria C11251-A
|
9/11/2023 |
| MCP 051 Genetic Testing - Effective 3/1/23 |
9/10/2023 |
|
MCP 216a Gender Affirmation Treatment and Procedures_Medicaid - Effective 3/1/23
|
9/10/2023 |
|
Adcetris (brentuximab vedotin) C15428-A - Effective 3/1/23
|
9/10/2023 |
|
Aduhelm (aducanumab-avwa) Medical Necessity Review C21304-A - Effective 3/1/23
|
9/10/2023 |
|
Amondys 45 (casimersen) Medical Necessity Review C21154-A - Effective 3/1/23
|
9/10/2023 |
|
Azactam (aztreonam) C10143-A - Effective 3/1/23
|
9/10/2023 |
|
Cancidas (caspofungin) C17928-A - Effective 3/1/23
|
9/10/2023 |
|
Copaxone_Glatopa (glatiramer acetate) C10270-A - Effective 3/1/23
|
9/10/2023 |
|
Cubicin (daptomycin) C10467-A - Effective 3/1/23
|
9/10/2023 |
|
Enjaymo (sutimlimab) C22996-A - Effective 3/1/23
|
9/10/2023 |
|
Exondys 51 (eteplirsen) Medical Necessity Review C18464-A - Effective 3/1/23
|
9/10/2023 |
|
Multiple Sclerosis Agents - Interferons C10267-A - Effective 3/1/23
|
9/10/2023 |
|
Nuzyra (omadacycline tosylate) C15914-A - Effective 3/1/23
|
9/10/2023 |
|
Ocrevus (ocrelizumab) C11250-A - Effective 3/1/23
|
9/10/2023 |
|
Prevymis (letermovir) C15922-A - Effective 3/1/23
|
9/10/2023 |
|
Reblozyl (luspatercept-aamt) C18002-A - Effective 3/1/23
|
9/10/2023 |
|
Sexual Dysfunction Criteria - Non-Coverage C16658-A - Effective 3/1/23
|
9/10/2023 |
|
Standard Oncology Criteria C16154-A - Effective 3/1/23
|
9/10/2023 |
|
Trogarzo (ibalizumab-uiyk) C14522-A - Effective 3/1/23
|
9/10/2023 |
|
Tysabri (natalizumab) C10276-A - Effective 3/1/23
|
9/10/2023 |
| Vibativ (telavancin) C14575-A - Effective 3/1/23 |
9/10/2023 |
|
Zinplava (bexlotoxumab) C14821-A - Effective 3/1/23
|
9/10/2023 |
|
Zulresso (brexanolone) C16319-A - Effective 3/1/23
|
9/10/2023 |
MCP 369 Facet Joint Allograft
|
9/6/2023 |
MCP 175 Transcatheter Aortic Valve Replacement
|
9/6/2023 |
UM-2-4010-D Clinical Criteria - Effective 3/1/23
|
9/1/2023 |
| UM-2-4400-D Criteria for Medical Necessity - Effective 3/1/23 |
9/1/2023 |
| UM-2-5200-D Criteria for Procedures that may Require Prior Authorization or Retrospective Review - Effective 3/1/23 |
9/1/2023 |
| UM-2-5235-D Criteria for Radiographs - Effective 3/1/23 |
9/1/2023 |
| UM-2-5245-D Criteria for Non-Restorable Tooth - Effective 3/1/23 |
9/1/2023 |
Xolair (omalizumab) C5678-A
|
8/17/2023 |
Radicava (edaravone) C11528-A
|
8/17/2023 |
Qutenza (capsaicin) C2809-A
|
8/17/2023 |
Mozobil (plerixafor injection) C9017-A
|
8/17/2023 |
Leukine (sargramostim) C2439-A
|
8/17/2023 |
Lemtrada (alemtuzumab) C6919-A
|
8/17/2023 |
Eylea (aflibercept) C5674-A
|
8/17/2023 |
| MCP 0311 Salpingectomy for Female Sterilization |
8/10/2023 |
Viltepso (vitolarsen) Medical Necessity Review C20406-A
|
8/1/2023
|
Sublocade (buprenorphine extended-release inj.) C15161-A
|
7/31/2023 |
MCP 120 Transarterial Chemoembolization (TACE) and Transarterial Embolization (TAE) for Liver Tumors
|
7/26/2023 |
MCP 208 Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury
|
7/26/2023 |
MCP 222 Interspinous Decompression Devices for Spinal Stenosis
|
7/26/2023 |
MCP 257 Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain (RACZ Procedure)
|
7/26/2023 |
MCP 266 Minimally Invasive Sacroiliac Joint Fusion
|
7/26/2023 |
MCP 282 Ozurdex (dexamethasone intravitreal implant)
|
7/26/2023 |
MCP 292 Phototherapy and Laser Therapy for Dermatological Conditions
|
7/26/2023 |
MCP 302 Retisert_Yutiq_fluocinolone acetonide_Intravitreal Implants
|
7/26/2023 |
MCP 314 Genicular Radiofrequency Ablation RFA and Genicular Nerve Blocks for Chronic Knee Pain
|
7/26/2023 |
MCP 332 Medically Necessary Services: Policy No. 332
|
7/26/2023 |
MCP 333 Steroid-Eluting Sinus Stents and Implants (PROPEL, SINUVA)
|
7/26/2023 |
MCP 338 Plantar Fasciitis Treatment
|
7/26/2023 |
MCP 339 Interspinous Process Fixation Devices for Spinal Fusion
|
7/26/2023 |
MCP 341 Smart Watch Photoplethysmography (PPG) for Detection of Atrial Fibrillation
|
7/26/2023 |
MCP 342 Dexycu (dexamethasone intraocular suspension)
|
7/26/2023 |
MCP 344 Ketogenic Diet for Treatment of Intractable Seizures
|
7/26/2023 |
MCP 350 MyoPro Orthosis
|
7/26/2023 |
| MCP 353 Electric Tumor Treatment Fields for Glioblastoma |
7/26/2023 |
MCP 361 Renal Autotransplantation
|
7/26/2023 |
MCP 362 Haploidentical Transplantation
|
7/26/2023 |
MCP 367 Scenesse (afamelanotide) Implant
|
7/26/2023 |
MCP 370 Durysta (bimatoprost) Implant
|
7/26/2023 |
MCP 385 Peroral Endoscopic Myotomy for Esophageal Achalasia
|
7/26/2023 |
| MCP 397 Moleculight Wound Care Device |
7/26/2023 |
MCP 404 Shoulder Arthroscopy
|
7/26/2023 |
MCP 405 Dextenza (dexamethasone intracanalicular insert)
|
7/26/2023 |
MCP 410 Genicular Artery Embolization of the Knee for Osteoarthritis
|
7/26/2023 |
MCP 411 Susvimo_ranibizumab intravitreal_injection implant
|
7/26/2023 |
MCP 662 Whole Body MRI
|
7/26/2023 |
MCP 218 Recombinant Human Bone Morphogenetic Protein
|
7/25/2023 |
MCP 207 Platelet Rich Plasma
|
7/25/2023 |
MCP 205 Functional Electrical Stimulation for Spinal Cord Injury
|
7/25/2023 |
MCP 184 Experimental and Investigational Services
|
7/25/2023 |
MCP 183 Clinical Trials and Rare Disease Policy
|
7/25/2023 |
MCP 161 Robotically Assisted Surgery
|
7/25/2023 |
MCP 133 Ambulatory and Video EEG Monitoring Outpatient Setting
|
7/25/2023 |
MCP 085 Radiofrequency Ablation for Chronic Back Pain
|
7/25/2023 |
MCP 033 Sacroiliac Injections and RFA for SIJ Pain
|
7/25/2023 |
MCP 030 Facet Joint Diagnostic Injections for Chronic Back Pain
|
7/25/2023 |
MCP 011 Artificial Disc Replacement
|
7/25/2023 |
MCP 006 Vagal Nerve Stimulation for Epilepsy
|
7/25/2023 |
MCP 295 High Intensity Focused Ultrasound for Prostate Cancer
|
7/6/2023 |
MCP 349 Zilretta_triamcinolone ER injection
|
7/6/2023 |
MCP 364b COVID-19 CoPays and Cost Share Medicaid
|
7/6/2023 |
MCP 401 Foot Surgery Guidelines
|
7/6/2023 |
MCP 649 Breast MRI
|
7/6/2023 |
MCP 357 Skin Substitutes for Chronic Wound Healing Outpatient
|
5/1/2023 |
| Pulmonary Arterial Hypertension (PAH) C9837-A |
4/17/2023 |
| Insulin Patch NC C24238-A |
3/28/2023 |
| MCP 045 Kidney Transplantation |
2/27/2023 |
| MCP 413 Carvykti (ciltacabtagene autoleucel) |
2/10/2023 |
| UM CARDIO_1121 Transthoracic Echocardiography |
2/1/2023 |
