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The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, use the menu on the right to select a category and narrow your search.
For information about policy numbers click
here.
For information about medical policies, the technology evaluation process, and claim payment policies click
here.
Policy #
Policy Bulletin Title
05.00.53e
Airway-Clearance Devices for Use in the Home Setting
05.00.39h
Ankle-Foot/Knee-Ankle-Foot Orthoses
05.00.29f
Automatic External and Wearable Cardioverter Defibrillators
05.00.16c
Blood Pressure Devices for Home Use
05.00.09d
Bone Growth Stimulators
05.00.61c
Cervical Traction for In-home Use
05.00.37c
Compression Garments
05.00.08c
Continuous Passive Motion (CPM) Devices in the Home Setting
05.00.25e
Cranial Remolding Orthoses (Helmets)
05.00.48f
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
05.00.21i
Durable Medical Equipment (DME)
05.00.05f
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.04b
Food and Drug Administration (FDA) Approval of Medical Devices
05.00.35b
Foot Orthotics and Other Podiatric Appliances
05.00.14f
High-Frequency Chest Wall Oscillation Devices
05.00.69
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
05.00.58e
Home Oxygen Therapy
05.00.63b
Home Use of Interferential and Sequential Stimulation Devices
05.00.65c
Home Uterine Activity Monitoring (HUAM) Devices
05.00.56e
Hospital Beds and Accessories
05.00.62d
Injectable Dermal Fillers
05.00.24h
Interstitial Continuous Glucose Monitoring Systems (CGMSs)
05.00.47g
Knee Braces
05.00.59e
Lower Limb Prostheses
05.00.12c
Manual Wheelchairs
05.00.70
Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures
05.00.15m
Nebulizers
05.00.38d
Negative Pressure Wound Therapy (NPWT) Systems
05.00.73
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
05.00.30e
Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices
05.00.50f
Ostomy Supplies
05.00.42d
Patient Lifts
05.00.01f
Pneumatic Compression Therapy Devices
05.00.54d
Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
05.00.60d
Pressure-Reducing Support Surfaces
05.00.26b
Prothrombin Time Monitor for Home Anticoagulation Management
05.00.31b
Pulse Oximetry Device in the Home Setting
05.00.44f
Repair and Replacement of Durable Medical Equipment (DME)
05.00.45f
Repair or Replacement of an External Prosthetic Device
05.00.43d
Seat Lift Mechanisms
05.00.32d
Speech- and Non-Speech-Generating Devices
05.00.71a
Standing Frames
05.00.11d
Therapeutic Shoes and Orthopedic Shoes
05.00.72a
Upper-Limb Prostheses
05.00.55g
Wheelchair Cushions and Seating
05.00.67f
Wheelchair Options and Accessories
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