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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, 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.
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Policy #
Policy Bulletin Title
07.00.21d
Allergy Immunotherapy
07.02.09
Ambulatory Blood Pressure Monitoring (ABPM)
07.02.07e
Ambulatory, Real-Time Cardiac Surveillance System
07.00.01e
Biofeedback Therapy
07.06.03a
Bioimpedance for the Detection of Lymphedema
07.02.12e
Cardiac Event Detection Monitoring (External Loop Monitoring)
07.00.14d
Cold Laser Therapy
07.13.11d
Corneal Liquid Bandage Lens for the Treatment of Persistent (Corneal) Epithelial Defects
07.13.07e
Corneal Pachymetry Using Ultrasound
07.06.01a
Decongestive Lymphedema Therapy (DLT)
07.05.07
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
07.07.07b
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
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07.03.09h
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.21f
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.16b
Electrosleep Therapy using a Cranial Electrical Stimulation Device
07.02.10b
End-Diastolic Pneumatic Compression Therapy
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07.03.07f
Evaluation and Management of Autism Spectrum Disorders (ASD)
07.03.15b
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
07.02.05h
External Counterpulsation (ECP)
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07.00.03i
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
07.02.03e
Implantable Cardiac Loop Monitor
07.00.05e
In Vivo Allergy Sensitivity Testing
07.03.14f
Intraoperative Neurophysiological Monitoring (INM)
07.00.02f
Intravenous Chelation Therapy
07.03.10d
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
07.11.02d
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
07.03.03d
Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
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07.03.18g
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.08c
Neuropsychological Evaluation/Testing
07.10.05
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System (Mirena®)
07.13.12a
Ocular Photoscreening
07.13.01e
Orthoptic/Pleoptic Training
07.10.04a
Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor
07.13.08c
Partial Coherence Interferometry
07.07.03h
Photodynamic Therapy (PDT) Using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA]) or Metvixia® (Methyl Aminolevulinate)
07.00.10f
Photodynamic Therapy (PDT) using Porfimer Sodium (Photofrin®)
07.13.05e
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)
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07.13.13
Prescription Lenses and Visual Devices
07.12.01b
Pulsed Magnetic Neuromodulation for Incontinence
07.00.15j
Reimbursement for the Administration of Immunizations
07.00.20d
Routine Costs Associated with Qualifying Clinical Trials
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07.07.01f
Routine Foot Care For Certain Medical Conditions
07.13.06f
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
07.03.05l
Sleep Disorder Testing
07.11.01a
Smell and Taste Dysfunction Testing
07.08.01d
Spinal Decompression Therapy
07.07.09b
Stem-Cell Therapy for Orthopedic Applications and Autologous Platelet-Derived Growth Factors (PDGFs)/Platelet-Rich Plasmas (PRPs) for Acute or Chronic Wound Healing and Other Miscellaneous Conditions
07.00.09c
Topical Oxygenation
07.05.06c
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
07.07.02e
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
07.07.05a
Whole-body Integumentary Photography and Dermatoscopy
07.05.02h
Wireless Capsule Endoscopy (WCE) using the Given® Diagnostic Imaging and PillCam™ Capsule Systems


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