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
07.00.21i
Allergy Immunotherapy
07.02.09g
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21e
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
07.10.06h
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
07.03.23c
Autonomic Nervous System Testing
07.00.01i
Biofeedback Therapy
07.06.03b
Bioimpedance for the Detection of Lymphedema
07.06.01b
Complete Decongestive Therapy (CDT)
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07.13.11i
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
07.13.11i
Attachment A (ICD-10 Codes) to 07.13.11i Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
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07.13.07j
Corneal Pachymetry Using Ultrasound
07.13.07j
Attachment A (ICD-10-CM codes) to 07.13.07j Corneal Pachymetry Using Ultrasound
07.05.07d
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
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07.03.09p
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment A (Recommended Guidelines for Electrodiagnostic Studies) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment B (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment C (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment D (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment E (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment F (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment G (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment H (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment I (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment J (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.09p
Attachment K (ICD-10 Codes) to 07.03.09p Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
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07.03.21k
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.21k
Attachment A (ICD-10-CM codes) to 07.03.21k Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.02.22a
Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
07.03.07t
Evaluation and Management of Autism Spectrum Disorder (ASD)
07.03.15d
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
07.02.05j
External Counterpulsation (ECP)
07.05.08a
Fecal Microbiota Transplantation (FMT)
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07.00.03n
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
07.00.03n
Attachment A (Utilization Guidelines) to 07.00.03n Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
07.03.01
Home-Based Sleep Studies
07.00.05g
In Vivo Allergy Sensitivity Testing
07.13.12d
Instrument-Based Vision Screening
07.03.14o
Intraoperative Neurophysiological Monitoring (INM)
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07.00.02i
Intravenous Chelation Therapy
07.00.02i
Attachment A (ICD-10 Codes) to 07.00.02i Intravenous Chelation Therapy
07.03.24a
Laboratory-Based Vestibular Function Testing
07.00.14g
Low-level Laser Therapy (LLLT)
07.03.10e
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
07.11.02f
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
07.08.03e
Medical and Surgical Treatment of Temporomandibular Joint Disorder
07.03.03g
Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
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07.03.18o
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment A (Recommended Guidelines for Electrodiagnostic Studies) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment B (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment C (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment D (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment E (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment F (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment G (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment H (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment I (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment J (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
07.03.18o
Attachment K (ICD-10 Codes) to 07.03.18o Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
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07.03.08i
Neuropsychological Testing for Neurologically Based Conditions
07.03.08i
Attachment A (ICD-10 Codes) to 07.03.08i Neuropsychological Testing for Neurologically Based Conditions
07.08.01f
Non-Surgical Spinal Decompression Therapy
07.10.05m
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
07.03.25a
Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home
07.13.01h
Orthoptic/Pleoptic Training
07.10.04c
Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor
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07.13.08e
Partial Coherence Interferometry
07.13.08e
Attachment A (ICD-10 Codes) to 07.13.08e Partial Coherence Interferometry
07.12.01e
Pelvic Floor Stimulation as a Treatment of Incontinence
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07.07.03m
Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
07.07.03m
Attachment A (ICD-10 Diagnosis Code Number(s) and Narrative(s)) to 07.07.03m Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
07.00.10i
Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
07.13.05k
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)
07.07.05b
Photography, Including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy
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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
07.00.15l
Reimbursement for the Administration of Immunizations
07.00.20f
Routine Costs Associated with Qualifying Clinical Trials
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07.07.01o
Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment A (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (A30.0 -E10.21)) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment B (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (E10.22 - E13.3512), Continued) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment C (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (E13.3513 - I87.093), Continued ) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment D (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (I87.099 - S86.891S), Continued) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.07.01o
Attachment E (ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (S86.892A - Z79.01), Continued) to 07.07.01o Routine Foot Care for Certain Medical Conditions
07.13.06k
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
07.03.05x
Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies (AmeriHealth)
07.11.01c
Smell and Taste Dysfunction Testing
07.07.09g
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
07.00.09d
Topical Oxygenation
07.05.06g
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
07.03.22d
Transcranial Magnetic Stimulation (TMS)
07.03.26a
Tumor Treating Fields
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07.07.02j
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
07.07.02j
Attachment A (ICD-10-CM codes ) to 07.07.02j Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
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07.05.02n
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
07.05.02n
Attachment A (ICD-10-CM Codes) to 07.05.02n Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon