Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
 
   


Policy #
Policy Bulletin Title

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07.13.13c
Prescription Lenses and Visual Devices
07.13.13c
Attachment A (Contains the applicable codes for prescription lenses and visual devices for Commercial (non-Medicare Advantage) members) to 07.13.13c Prescription Lenses and Visual Devices
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08.00.08j
Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (AmeriHealth Administrators)
08.00.10b
Luspatercept–aamt (Reblozyl®)
08.00.12a
Fam-trastuzumab deruxtecan-nxki (Enhertu®)
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08.00.13x
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.15f
Off-label Coverage for Prescription Drugs and/or Biologics
08.00.17h
Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)
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08.00.18m
Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
08.00.22m
Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
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08.00.25l
Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
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08.00.26w
Botulinum Toxin Agents
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08.00.33o
Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
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08.00.34n
Infliximab and Related Biosimilars
08.00.43a
Enfortumab vedotin-ejfv (Padcev™)
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08.00.45a
Eptinezumab-jjmr (VYEPTI™)
08.00.46
Isatuximab-irfc (Sarclisa®)
08.00.49e
Dofetilide (Tikosyn®) Use in the Inpatient Setting
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08.00.50v
Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
08.00.51j
Enzyme Replacement for the Treatment of Gaucher's Disease
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08.00.55h
Omalizumab (Xolair®)
08.00.57n
Treatments for Complex Regional Pain Syndrome (CRPS)
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08.00.62j
Abatacept (Orencia®) for Injection for Intravenous Use
08.00.64g
Natalizumab (Tysabri®)
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08.00.66n
Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use
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08.00.67l
Cetuximab (Erbitux®)
08.00.69b
Agalsidase beta (Fabrazyme®)
08.00.70e
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
08.00.72h
Alglucosidase alfa (e.g., Lumizyme®)
08.00.73l
Bortezomib (Bortezomib for Injection, Velcade®)
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08.00.74n
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
08.00.75n
Erythropoiesis-Stimulating Agents (ESAs)
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08.00.78ae
Self-Administered Drugs
08.00.82k
Ustekinumab (Stelara®)
08.00.84g
Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®)
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08.00.85i
Tocilizumab (Actemra®) for Intravenous Infusion
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08.00.87f
Pemetrexed (Alimta®)
08.00.88f
Ofatumumab (Arzerra®)
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08.00.90k
Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-Bound)/(Abraxane® for Injectable Suspension)
08.00.91d
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
08.00.92ab
Coagulation Factors
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08.00.94m
Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
08.00.95d
Personalized Vaccines (e.g. Provenge®)
08.00.96e
Cabazitaxel (Jevtana®)
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08.00.98e
Eribulin Mesylate (Halaven®)
08.00.99c
Belimumab (Benlysta®) for Intravenous Use
08.01.00g
Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies
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08.01.01i
Ipilimumab (Yervoy®)
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08.01.02e
Pegloticase (Krystexxa®)
08.01.04v
Immunizations
08.01.05f
Carfilzomib (Kyprolis™)
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08.01.07f
Pertuzumab (Perjeta®)
08.01.08d
Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
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08.01.10f
Octreotide Acetate (Sandostatin® LAR Depot)
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08.01.11e
Ado-Trastuzumab Emtansine (Kadcyla®)
08.01.12b
Repository Corticotropin (H.P. Acthar® Gel Injection)
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08.01.13d
Brentuximab Vedotin (Adcetris®)
08.01.14e
Radium Ra 223 dichloride (Xofigo®) Injection (AmeriHealth Administrators)
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08.01.15d
Golimumab (Simponi Aria®) Intravenous (IV) Injection
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08.01.18e
Vedolizumab (Entyvio®)
08.01.19f
Siltuximab (Sylvant®)
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08.01.20j
Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
08.01.21c
Blinatumomab (Blincyto®)
08.01.22d
Alemtuzumab (Lemtrada®)
08.01.23f
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra®)
08.01.24a
Deoxycholic Acid (Kybella™)
08.01.25d
Ramucirumab (Cyramza®)
08.01.26c
Enzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., elapegademase-lvlr [Revcovi™)
08.01.28d
Sebelipase alfa (Kanuma®)
08.01.29f
Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro™)
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08.01.32c
Pegfilgrastim (Neulasta®) and Related Biosimilars
08.01.33b
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
08.01.35b
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
08.01.36e
Therapies for Spinal Muscular Atrophy Nusinersen (Spinraza®) and Onasemnogene abeparvovec-xioi (Zolgensma®)
08.01.37a
Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Naltrexone Implants, Probuphine Implant, Sublocade Injection, Vivitrol Injection)
08.01.38c
Ocrelizumab (Ocrevus®)
08.01.39c
Cerliponase alfa (Brineura®)
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08.01.40b
Lanreotide (Somatuline® Depot)
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08.01.41c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
08.01.42a
Edaravone (Radicava™)
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08.01.43e
Chimeric Antigen Receptor (CAR) Therapy
08.01.44c
Voretigene Neparvovec-rzyl (Luxturna™)
08.01.46a
Ibalizumab-uiyk (Trogarzo™)
08.01.47a
Triamcinolone Acetonide Extended-Release Injectable (Zilretta™)
08.01.48b
Tildrakizumab-asmn (Ilumya™)
08.01.49a
Burosumab-twza (Crysvita®)
08.01.50b
Patisiran (Onpattro™)
08.01.51
Canakinumab (Ilaris®)
08.01.52b
Mogamulizumab-kpkc (Poteligeo®)
08.01.53b
Moxetumomab Pasudotox-tdfk (Lumoxiti™)
08.01.54b
Emapalumab-lzsg (Gamifant®)
08.01.55c
Tagraxofusp-erzs (Elzonris™)
08.01.57
Lutathera® (Lutetium Lu 177 Dotatate) (AmeriHealth Administrators)
08.01.59b
Polatuzumab Vedotin-Piiq (Polivy™)
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08.01.60
Sacituzumab govitecan-hziy (TrodelvyTM)
08.01.66
Cemiplimab-rwlc (LIBTAYO®)
09.00.02e
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
09.00.04k
Bone Mineral Density (BMD) Testing
09.00.10z
Brachytherapy and Accelerated Whole Breast Irradiation using Three-Dimensional Conformation Radiation Therapy (AmeriHealth Administrators)
09.00.11d
Contrast Agents Used in Conjunction with Echocardiography
09.00.13c
High Osmolar Contrast Agents
09.00.17o
Intensity-Modulated Radiation Therapy (IMRT) (AmeriHealth Administrators)
09.00.24c
Full-Body Computerized Tomography (CT) Scan Screening
09.00.31d
Low Osmolar Contrast Agents
09.00.32u
Reimbursement for Radiopharmaceutical Agents for Professional Providers
09.00.36l
First-Trimester Prenatal Screening for Fetal Aneuploidy Using Fetal Ultrasound Markers
09.00.40d
Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA)
09.00.42c
Computer-Aided Detection (CAD) System for Use with Chest Radiographs
09.00.45h
Magnetic Resonance Imaging (MRI) Contrast Agents
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09.00.46ab
High-Technology Radiology Services (AmeriHealth)
09.00.48g
Radioembolization for Primary and Metastatic Tumors of the Liver (AmeriHealth Administrators)
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09.00.49l
Proton Beam Radiation Therapy
09.00.51a
Positron Emission Mammography (PEM)
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09.00.56j
Radiation Therapy Services (AmeriHealth)
10.00.02c
Day Rehabilitation
10.00.03
Pediatric Intensive Day Feeding Program
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10.01.01n
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
10.02.02j
Chiropractic Spinal and Extraspinal Manipulation Therapy
10.03.01l
Physical Medicine, Rehabilitation, and Habilitation Services
10.04.01l
Pulmonary Rehabilitation
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10.06.01l
Speech Therapy
11.00.02f
Treatment of Medical and Surgical Complications
11.00.03j
Fetal Surgery
11.00.06k
Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring
11.00.09f
Solid Organ Transplantation and Procurement Cost of Organs and Tissues
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11.00.10w
Multiple Surgery Payment Reduction
11.00.13g
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-abdominal and Pelvic Malignancies
11.00.14f
Treatment of Twin-Twin Transfusion Syndrome (TTTS)
11.00.16g
Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors
11.00.18a
Use of a Robotic-Assisted Surgical System
11.01.01j
Otoplasty or Non-Surgical External Ear Molding
11.01.02o
Cochlear Implant
11.01.06e
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
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11.01.07e
Cataract Surgery
11.02.01s
Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence
11.02.06m
Catheter Ablation of Cardiac Arrhythmias
11.02.10n
Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
11.02.11g
Transcatheter Closure of Cardiac Septal Defects
11.02.12i
Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery
11.02.16r
Ventricular Assist Devices (VADs)
11.02.17f
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
11.02.19f
Total Artificial Hearts (TAHs)
11.02.25g
Transcatheter Cardiac Valve Procedures
11.02.26b
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
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11.02.27b
Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (AmeriHealth)
11.03.01e
Repair of Cleft Lip, Cleft Nose, and/or Cleft Palate
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11.03.02s
Bariatric Surgery
11.03.05d
Frenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie)
11.03.11n
Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
11.03.12s
Colorectal Cancer Screening
11.03.15h
Gastric Electrical Stimulation (Enterra™), Gastric Pacing
11.04.01d
Islet Cell Transplantation
11.05.01f
Refractive Keratoplasty
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11.05.02i
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
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11.05.07d
Surgical Correction of Strabismus
11.05.08d
Photocoagulation of Macular Drusen
11.05.10b
Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens
11.05.11c
Implantation of Intrastromal Corneal Ring Segments (ICRS)
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11.05.16h
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
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11.06.02i
Elective Abortion
11.06.04k
Uterine Artery Embolization
11.06.05f
Endometrial Ablation
11.06.06e
Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation
11.06.07d
Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
11.06.09d
Labiaplasty
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11.07.01t
Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
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11.07.02j
Sentinel Lymph Node Biopsy and Mapping
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11.08.01g
Hair Transplants and Cranial Prostheses (Wigs)
11.08.02h
Reduction Mammoplasty
11.08.03j
Lipectomy and Liposuction
11.08.04h
Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
11.08.05g
Application and Removal of Tattoos
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11.08.06j
Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
11.08.08g
Chemical Peels
11.08.12h
Surgery for Gynecomastia
11.08.13g
Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
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11.08.14k
Removal of Breast Implants
11.08.15x
Reconstructive Breast Surgery
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11.08.17i
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
11.08.19o
Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
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11.08.20v
Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
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11.08.23j
Mohs' Micrographic Surgery
11.08.25m
Scar Revision
11.08.29e
Procedures for the Treatment of Acne
11.09.02h
Treatment of Gender Dysphoria
11.11.01i
Evaluation and Treatment of Erectile Dysfunction (ED)
11.11.03d
Cryosurgical Ablation of the Prostate Gland
11.11.06h
Saturation Needle Biopsy of the Prostate
11.14.01g
Mentoplasty or Genioplasty
11.14.02o
Trigger Point Injections
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11.14.03g
Meniscal Allograft Transplantation and Meniscal Implants
11.14.06i
Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
11.14.07v
Intra-Articular Injection of Hyaluronan for the Treatment of Osteoarthritis
11.14.08d
Orthognathic Surgery
11.14.09g
Osteochondral Autograft Transplantation (OAT) Procedure
11.14.10r
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
11.14.12e
Osteochondral Allograft Transplantation
11.14.13g
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
11.14.14e
Percutaneous Intradiscal Annuloplasty (IDET/PIRFT)
11.14.17d
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures