Oxford Health Plans > Practical Resources > Medical & Administrative Policy Index

Medical & Administrative Policy Index

A complete library of our clinical, administrative and reimbursement policies is available below for your reference. The appearance of an item or procedure on the list indicates only that we have adopted a policy; it does not imply that we provide coverage for the item or procedure listed.

The services described in our policies are subject to the terms, conditions and limitations of the member's contract or certificate. Unless otherwise stated, our policies do not apply to Medicare Advantage enrollees. We reserve the right, in our sole discretion, to modify policies as necessary without prior written notice unless otherwise required by our administrative procedures or applicable state law. The terms "our" and "we" include Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to self-funded members and certain insured products. Refer to the member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member's plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.


Policy Type Policy Title Effective Date
Clinical17-Alpha-Hydroxyprogesterone Caproate (Makena® and 17P) 09/01/2021
ClinicalAblative Treatment for Spinal Pain 02/01/2021
ClinicalAbnormal Uterine Bleeding and Uterine Fibroids 07/01/2021
AdministrativeAbortions (Therapeutic and Elective) 10/01/2021
AdministrativeAccreditation Requirements for Radiology Services 06/01/2020
AdministrativeAcquired Rare Disease Drug Therapy Exception Process 09/01/2020
ClinicalActemra® (Tocilizumab) Injection for Intravenous Infusion 10/01/2021
ReimbursementAcupuncture 10/01/2020
ClinicalAdakveo® (Crizanlizumab-Tmca) 04/01/2021
ReimbursementAdd-On Policy 09/01/2021
ReimbursementAdvanced Practice Health Care Provider 08/01/2021
ReimbursementAfter Hours and Weekend Care 06/01/2021
ClinicalAirway Clearance Devices 10/01/2021
ClinicalAlpha1-Proteinase Inhibitors 12/01/2020
ReimbursementAmbulance 10/11/2021
AdministrativeAmbulance Services 08/01/2021
ClinicalAmondys 45™ (Casimersen) 10/01/2021
ClinicalAntiemetics for Oncology 08/01/2021
ClinicalApheresis 02/01/2021
ClinicalArticular Cartilage Defect Repairs 07/01/2021
AdministrativeAssignment of Benefits and Balance Billing 06/01/2020
ReimbursementAssistant-at-Surgery 08/01/2021
ClinicalAssisted Administration of Clotting Factors, Coagulant Blood Products & Other Hemostatics 01/01/2021
ClinicalAthletic Pubalgia Surgery 07/01/2021
ClinicalAttended Polysomnography for Evaluation of Sleep Disorders 07/01/2021
AdministrativeAutism 10/01/2021
ClinicalAutologous Cellular Therapy 10/01/2021
ReimbursementB Bundle Codes (CES) 08/01/2021
ClinicalBalloon Sinus Ostial Dilation 08/01/2021
ClinicalBariatric Surgery12/01/2020
ClinicalBeds and Mattresses05/01/2021
AdministrativeBehavioral Health Services 10/01/2021
ClinicalBenlysta® (Belimumab) 04/01/2021
ReimbursementBilateral Procedures (CES) 08/01/2021
ClinicalBlepharoplasty, Blepharoptosis and Brow Ptosis Repair 04/01/2021
ClinicalBone or Soft Tissue Healing and Fusion Enhancement Products 09/01/2020
ClinicalBotulinum Toxins A and B 04/01/2021
ClinicalBreast Imaging for Screening and Diagnosing Cancer 10/01/2021
ClinicalBreast Reconstruction Post Mastectomy and Poland Syndrome 10/01/2021
ClinicalBreast Reduction Surgery 05/01/2021
ClinicalBreast Repair/Reconstruction Not Following Mastectomy 01/01/2021
ClinicalBrineura® (Cerliponase Alfa) 08/01/2021
ClinicalBronchial Thermoplasty 08/01/2021
ClinicalBuprenorphine (Probuphine® & Sublocade®) 11/01/2020
ClinicalCardiac Event Monitoring 07/01/2021
ClinicalCardiology Procedures Requiring Prior Authorization for eviCore healthcare Arrangement 06/01/2021
ClinicalCardiovascular Disease Risk Tests 03/01/2021
ReimbursementCare Plan Oversight 08/01/2021
ClinicalCarrier Testing for Genetic Diseases 09/01/2021
ClinicalCatheter Ablation for Atrial Fibrillation 09/01/2021
ClinicalCell-Free Fetal DNA Testing 10/01/2021
ClinicalChelation Therapy for Non-Overload Conditions 05/01/2021
ClinicalChemosensitivity and Chemoresistance Assays in Cancer 11/01/2020
ClinicalChromosome Microarray Testing (Non-Oncology Conditions) 10/01/2021
ClinicalCimzia® (Certolizumab Pegol) 10/01/2021
AdministrativeClaims Recovery 01/01/2021
AdministrativeClinical Review 02/01/2021
ClinicalClinical Trials 05/01/2021
ClinicalClotting Factors, Coagulant Blood Products & Other Hemostatics 04/01/2021
ClinicalCochlear Implants 07/01/2021
ClinicalCollagen Crosslinks and Biochemical Markers of Bone Turnover 04/01/2021
ClinicalComplement Inhibitors (Soliris® & Ultomiris™) 10/01/2021
ClinicalComputer-Assisted Surgical Navigation for Musculoskeletal Procedures 10/01/2021
ClinicalComputerized Dynamic Posturography 05/01/2021
ReimbursementConsultation Services 05/01/2021
ClinicalContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes 08/01/2021
AdministrativeContraceptives 09/01/2020
AdministrativeCoordination of Benefits 03/01/2021
ClinicalCore Decompression for Avascular Necrosis 12/01/2020
ClinicalCorneal Hysteresis and Intraocular Pressure Measurement 08/01/2021
ClinicalCosmetic and Reconstructive Procedures 08/01/2021
ReimbursementCo-Surgeon/Team Surgeon (CES) 10/01/2021
AdministrativeCredentialing Guidelines: Participation in the eviCore healthcare Network 02/01/2020
ClinicalCrysvita® (Burosumab-Twza) 10/01/2021
ClinicalCytological Examination of Breast Fluids for Cancer Screening or Diagnosis 09/01/2021
ClinicalDeep Brain and Cortical Stimulation 07/01/2021
ClinicalDenosumab (Prolia® & Xgeva®) 10/01/2021
AdministrativeDental and Oral Surgical Procedures 04/01/2021
AdministrativeDiabetes Supply Coverage 06/01/2021
AdministrativeDialysis Services 03/01/2021
AdministrativeDisclosure Policy 09/01/2020
ClinicalDiscogenic Pain Treatment 12/01/2020
ReimbursementDiscontinued Procedure (CES) 07/01/2020
ClinicalDrug Coverage Criteria - New and Therapeutic Equivalent Medications 10/01/2021
ClinicalDrug Coverage Guidelines 10/01/2021
ReimbursementDrug Testing 09/01/2021
AdministrativeDurable Medical Equipment, Orthotics, Medical Supplies and Repairs/Replacements 09/01/2021
ReimbursementDurable Medical Equipment, Orthotics and Prosthetics (CES) 08/01/2021
ClinicalElective Inpatient Services 05/01/2021
ClinicalElectric Tumor Treatment Field Therapy 03/01/2021
ClinicalElectrical and Ultrasound Bone Growth Stimulators 01/01/2021
ClinicalElectrical Bioimpedance for Cardiac Output Measurement 09/01/2021
ClinicalElectrical Stimulation and Electromagnetic Therapy for Wounds 04/01/2021
ClinicalElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation 08/01/2021
ClinicalElectroencephalographic (EEG) Monitoring and Video Recording 07/01/2021
ClinicalEloctate™ (Antihemophilic Factor (Recombinant), FC Fusion Protein) for Connecticut Lines of Business 04/01/2021
ClinicalEmbolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome 05/01/2021
AdministrativeEmergency Room Visits (Including Coverage for Members Outside of the United States) 09/01/2021
ClinicalEntyvio® (Vedolizumab) 04/01/2021
ClinicalEpidural Steroid Injections for Spinal Pain 10/01/2021
ClinicalEpiduroscopy, Epidural Lysis of Adhesions and Discography 02/01/2021
ClinicalErythropoiesis-Stimulating Agents 11/01/2020
ReimbursementEvaluation and Management (E/M) 08/01/2021
ClinicalEvenity® (Romosozumab-Aqqg) 12/01/2020
ClinicalEvkeeza™ (Evinacumab-dgnb) 10/01/2021
ClinicalExondys 51® (Eteplirsen) 04/01/2021
AdministrativeExperimental/Investigational Treatment 09/01/2020
AdministrativeExperimental/Investigational Treatment for NJ Plans 09/01/2020
AdministrativeExtended Benefits for Total Disability & Succeeding Carrier for Inpatient Admissions 10/01/2021
ClinicalExtracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds 08/01/2021
ClinicalFacet Joint Injections for Spinal Pain 05/01/2021
ClinicalFecal Calprotectin Testing 06/01/2021
AdministrativeFiling Deadlines for Claims Submissions 12/01/2019
ClinicalFollicle Stimulating Hormone (FSH) Gonadotropins 09/01/2020
AdministrativeFollow-Up Care Rendered in an Emergency Room Site of Service 10/01/2020
AdministrativeFormula and Specialized Food 10/01/2021
ReimbursementFrom - To Date Policy 10/11/2021
ClinicalFunctional Endoscopic Sinus Surgery (FESS) 02/01/2021
ClinicalGamifant® (Emapalumab-Lzsg) 01/01/2021
ClinicalGastrointestinal Motility Disorders, Diagnosis and Treatment 07/01/2021
ClinicalGastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea 03/01/2021
ClinicalGender Dysphoria Treatment 10/01/2021
ClinicalGenetic Testing for Cardiac Disease 07/01/2021
ClinicalGenetic Testing for Hereditary Cancer 01/01/2021
ClinicalGenetic Testing for Neuromuscular Disorders 10/01/2021
ClinicalGenitourinary Pathogen Nucleic Acid Detection Panel Testing 04/01/2021
ClinicalGivlaari™ (Givosiran) 04/01/2021
ClinicalGlaucoma Surgical Treatments 08/01/2021
ReimbursementGlobal Days 07/12/2021
ClinicalGonadotropin Releasing Hormone Analogs 10/01/2021
ClinicalGynecomastia Treatment 05/01/2021
ClinicalHearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable 08/01/2021
ClinicalHereditary Angioedema (HAE), Treatment and Prophylaxis 05/01/2021
ClinicalHome Health Care 08/01/2021
ClinicalHome Hemodialysis 05/01/2021
ClinicalHome Traction Therapy 07/01/2021
ClinicalHuman Menopausal Gonadotropins (hMG) 09/01/2020
ClinicalHysterectomy 10/01/2021
ClinicalIlaris® (Canakinumab) 10/01/2021
ClinicalIlumya™ (Tildrakizumab-Asmn) 02/01/2021
ClinicalImmune Globulin (IVIG and SCIG) 04/01/2021
ClinicalImmune Globulin - Site of Care 06/01/2021
ClinicalImplantable Beta-Emitting Microspheres for Treatment of Malignant Tumors 08/01/2021
ClinicalImplanted Electrical Stimulator for Spinal Cord 10/01/2021
ReimbursementIncreased Procedural Services (CES) 06/01/2021
ClinicalInfertility Diagnosis and Treatment 07/01/2021
ClinicalInfliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) 09/01/2021
ClinicalInhaled Nitric Oxide for Infants 10/01/2021
ReimbursementInjection and Infusion Services (CES) 10/01/2021
AdministrativeIn-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy 06/01/2021
ReimbursementIn-Office Laboratory Testing and Procedures List 06/01/2021
AdministrativeInpatient Maternity Stay and Subsequent Home Nursing 12/01/2019
ReimbursementInpatient Unacceptable Principal Diagnosis 08/01/2021
ClinicalIntraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) 09/01/2020
ReimbursementIntraoperative Neuromonitoring 05/01/2021
ClinicalIntrauterine Fetal Surgery 09/01/2021
ClinicalIntravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease 04/01/2021
ClinicalIntravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) 08/01/2021
ClinicalKrystexxa® (Pegloticase) 11/01/2020
ClinicalLaser Interstitial Thermal Therapy 07/01/2021
ClinicalLemtrada (Alemtuzumab) 05/01/2021
ClinicalLight and Laser Therapy 11/01/2020
ClinicalLiposuction for Lipedema 10/01/2021
ClinicalLithotripsy for Salivary Stones 11/01/2020
ClinicalLong-Acting Injectable Antiretroviral Agents for HIV 10/01/2021
ClinicalLower Extremity Invasive Diagnostic and Endovascular Procedures 07/01/2021
ClinicalLuxturna™ (Voretigene Neparvovec-Rzyl) 12/01/2020
ClinicalLyme Disease 12/01/2020
ClinicalMacular Degeneration Treatment Procedures 07/01/2021
ClinicalMagnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan – Site of Service 02/01/2021
ClinicalManipulation Under Anesthesia 04/01/2021
ClinicalManipulative Therapy 07/01/2021
ClinicalManual Wheelchairs 05/01/2021
ClinicalMaximum Dosage and Frequency10/01/2021
ReimbursementMaximum Frequency Per Day (CES) 10/11/2021
ClinicalMechanical Stretching Devices 01/01/2021
ClinicalMedical Therapies for Enzyme Deficiencies 10/01/2021
AdministrativeMember Administrative Grievance and Appeal (Non UM) Process & Timeframes 12/01/2019
ClinicalMeniscus Implant and Allograft 09/01/2021
ReimbursementMicrosurgery (CES) 10/01/2021
ClinicalMifeprex® (Mifepristone) 05/01/2021
ClinicalMinimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) and Achalasia 07/01/2021
ReimbursementModifier Reference (CES) 07/01/2021
ReimbursementModifier SU 04/01/2020
ReimbursementMohs Micrographic Surgery 06/01/2020
ClinicalMolecular Oncology Testing for Cancer Diagnosis, Prognosis and Treatment Decisions 10/01/2021
ClinicalMotorized Spinal Traction 07/01/2021
ReimbursementMultiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures 09/01/2021
ReimbursementMultiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging 09/01/2021
ReimbursementMultiple Procedures Payment Reduction (MPPR) for Medical and Surgical Services 10/01/2021
ClinicalNegative Pressure Wound Therapy 03/01/2021
ClinicalNerve Graft to Restore Erectile Function During Radical Prostatectomy 01/01/2021
ClinicalNeurophysiologic Testing and Monitoring 01/01/2021
ClinicalNeuropsychological Testing Under the Medical Benefit 09/01/2021
ReimbursementNew Patient Visit 09/01/2021
AdministrativeNewborns 03/01/2020
ReimbursementNonphysician Health Care Codes 07/12/2021
ReimbursementNonphysician Health Care Professionals Billing Evaluation and Management Codes 09/01/2021
ReimbursementObservation and Discharge 09/01/2021
ClinicalObservation Services 05/01/2021
ReimbursementObstetrical Policy 10/11/2021
ClinicalObstetrical Ultrasonography 01/01/2021
ClinicalObstructive Sleep Apnea Treatment 10/01/2021
ClinicalOccipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) 10/01/2021
ClinicalOcrevus®(Ocrelizumab) 09/01/2021
ClinicalOffice Based Procedures - Site of Service 08/01/2021
ClinicalOff-Label/Unproven Specialty Drug Treatment 08/01/2021
ClinicalOmnibus Codes 10/01/2021
ReimbursementOnce In a Lifetime Procedures 09/01/2021
ClinicalOncology Medication Clinical Coverage 08/01/2021
ReimbursementOne or More Sessions (CES) 10/01/2021
ClinicalOnpattro®(Patisiran) 08/01/2021
ClinicalOrencia® (Abatacept) Injection for Intravenous Infusion 09/01/2021
ClinicalOrthognathic (Jaw) Surgery 07/01/2021
AdministrativeOrthopedic Services 01/01/2021
ClinicalOtoacoustic Emissions Testing 10/01/2021
ClinicalOutpatient Physical and Occupational Therapy 10/01/2021
ReimbursementOutpatient Rehabilitation Therapy Services 06/01/2021
ClinicalOutpatient Surgical Procedures - Site of Service 08/01/2021
ClinicalOxford's Outpatient Imaging Self-Referral 01/01/2021
ClinicalOxlumo™ (Lumasiran) 07/01/2021
ClinicalPanniculectomy and Body Contouring Procedures 10/01/2021
ClinicalParsabiv® (Etelcalcetide) 04/01/2021
AdministrativeParticipating Gastroenterologists Using Non-Participating Anesthesiologists: In-Office and Ambulatory Surgery Centers Protocol 05/01/2020
AdministrativeParticipating Providers Using Non-Participating Laboratory and Pathology Providers Protocol 05/01/2020
AdministrativeParticipating Providers Using Non-Participating Providers Protocol 05/01/2020
AdministrativeParticipating Surgeons Using Non-Participating Assistant Surgeons and Co-Surgeons Protocol 05/01/2020
AdministrativeParticipating Surgeons Using Non-Participating Providers for Intraoperative Neuro-Monitoring (IONM) Protocol) 05/01/2020
ClinicalPatient Lifts 05/01/2021
ClinicalPectus Deformity Repair 07/01/2021
ReimbursementPediatric and Neonatal Critical and Intensive Care Services 06/01/2021
ClinicalPediatric Gait Trainers, Standing Systems and Walkers 05/01/2021
ClinicalPediatric Outpatient Intensive Feeding Programs 05/01/2021
ClinicalPercutaneous Patent Foramen Ovale (PFO) Closure 04/01/2021
ClinicalPercutaneous Vertebroplasty and Kyphoplasty 12/01/2020
ClinicalPharmacogenetic Testing 05/01/2021
ReimbursementPhysical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction 02/01/2021
ReimbursementPhysical Medicine & Rehabilitation: PT, OT and Evaluation & Management 01/11/2021
ReimbursementPhysical Medicine & Rehabilitation: Speech Therapy 01/11/2021
ClinicalPhysical, Occupational, and Speech Therapy including Cognitive/Neuropsychological Rehabilitation for New Jersey Small Group Members 10/01/2021
ClinicalPlagiocephaly and Craniosynostosis Treatment 08/01/2021
ClinicalPneumatic Compression Devices 07/01/2021
ClinicalPower Mobility Devices 09/01/2021
AdministrativePractitioner/Provider Administrative Claim Reconsideration and Appeal Process 01/01/2021
ClinicalPreimplantation Genetic Testing 07/01/2021
ClinicalPreventive Care Services 10/01/2021
ReimbursementPreventive Medicine and Screening (CES) 01/11/2021
AdministrativePrior Authorization Exemptions for Outpatient Services 10/01/2021
ClinicalPrivate Duty Nursing (PDN) Services 07/01/2021
ReimbursementProcedure and Place of Service07/12/2021
ReimbursementProlonged Services 07/01/2021
ClinicalProlotherapy and Platelet Rich Plasma Therapies 08/01/2021
ClinicalProstate Surgeries and Interventions 10/01/2021
ClinicalProsthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs 10/01/2021
ClinicalProvider Administered Drugs – Site of Care 10/01/2021
ClinicalRadiation Therapy Procedures Requiring Prior Authorization for eviCore heathcare Arrangement 01/01/2021
ClinicalRadicava® (Edaravone) 04/01/2021
ClinicalRadiology Procedures Requiring Prior Authorization for eviCore heathcare Arrangement 06/01/2021
ClinicalRadiopharmaceuticals and Contrast Media 01/01/2021
ClinicalReblozyl® (Luspatercept-Aamt) 08/01/2021
ReimbursementReduced Services (CES) 06/01/2020
AdministrativeReferrals 07/01/2021
ReimbursementReimbursement for Comprehensive and Component CPT Codes (CES) 03/01/2020
ReimbursementReplacement Codes 01/11/2021
ClinicalRepository Corticotropin Injection (Acthar Gel®) 06/01/2021
AdministrativeRequests for In-Network Exceptions 09/01/2020
ClinicalRespiratory Interleukins (Cinqair®, Fasenra®, and Nucala®) 10/01/2021
ClinicalReview at Launch for New to Market Medications 10/01/2021
ClinicalRhinoplasty and Other Nasal Surgeries 10/01/2021
ClinicalRituximab (Riabni™, Rituxan®, Ruxience® & Truxima®) 10/01/2021
ReimbursementRobotic Assisted Surgery 12/01/2020
ClinicalRoutine Foot Care 05/01/2021
ClinicalRyplazim® (Plasminogen, Human-Tvmh) 10/01/2021
ClinicalSacroiliac Joint Injections 10/01/2021
ReimbursementSame Day/Same Service (CES) 11/01/2020
ClinicalSandostatin LAR® Depot (Octreotide Acetate) 12/01/2020
ClinicalSaphnelo (Anifrolumab-Fnia) 10/01/2021
ClinicalScenesse® (Afamelanotide) 08/01/2021
ClinicalScreening Colonoscopy Procedures – Site of Service 10/01/2021
ClinicalSensory Integration Therapy and Auditory Integration Training 12/01/2020
ReimbursementServices and Modifiers Not Reimbursable to Healthcare Professionals 01/01/2021
ReimbursementServices Incident-to a Supervising Health Care Provider 08/01/2021
AdministrativeServices Requiring Prior Authorization 10/01/2021
ClinicalSimponi Aria® (Golimumab) Injection for Intravenous Infusion 09/01/2021
ReimbursementSite of Service Differential 10/01/2021
AdministrativeSkilled Care and Custodial Care Services 07/01/2021
ClinicalSkin and Soft Tissue Substitutes 10/01/2021
ClinicalSodium Hyaluronate 04/01/2021
ReimbursementSpecialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting 10/01/2020
ClinicalSpeech Generating Devices 07/01/2021
AdministrativeSpeech Therapy and Early Intervention Programs/Birth to Three 09/01/2020
ClinicalSpinraza® (Nusinersen) 07/01/2021
ReimbursementSplit Surgical Package (CES) 08/01/2020
ClinicalSpravato® (Esketamine) 06/01/2021
ReimbursementStandby Services 06/01/2020
ClinicalStelara® (Ustekinumab) 09/01/2021
ReimbursementSupply Policy 10/11/2021
ClinicalSurgery of the Elbow 07/01/2021
ClinicalSurgery of the Foot 09/01/2021
ClinicalSurgery of the Hip 07/01/2021
ClinicalSurgery of the Knee 09/01/2021
ClinicalSurgery of the Shoulder 09/01/2021
ClinicalSurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins 07/01/2021
ClinicalSurgical Treatment for Spine Pain 09/01/2021
ClinicalSynagis® (Palivizumab) 08/01/2021
ReimbursementT Status Codes (CES) 02/08/2021
ReimbursementTelehealth/Telemedicine (CES) 04/19/2021
ClinicalTemporomandibular Joint Disorders 07/01/2021
ClinicalTepezza® (Teprotumumab-Trbw) 05/01/2021
ClinicalTherapeutic Shoes and Inserts for Diabetes 05/01/2021
ClinicalThermography 05/01/2021
ReimbursementTime Span Codes 04/19/2021
AdministrativeTimeframe Standards for Benefit Administrative Initial Decisions 10/01/2021
AdministrativeTimeframe Standards for Utilization Management (UM) Initial Decisions 05/01/2020
ClinicalTotal Artificial Disc Replacement for the Spine 07/01/2021
ClinicalTotal Artificial Heart and Ventricular Assist Devices 05/01/2021
ClinicalTranscatheter Heart Valve Procedures 09/01/2021
ClinicalTranscranial Magnetic Stimulation 04/01/2021
ClinicalTranscutaneous Electrical Nerve/Joint Stimulators 10/01/2021
ClinicalTranspupillary Thermotherapy 06/01/2021
ClinicalTrogarzo® (Ibalizumab-Uiyk) 04/01/2021
ClinicalTysabri® (Natalizumab) 05/01/2021
ClinicalUmbilical Cord Blood Harvesting and Storage for Future Use 07/01/2021
ClinicalUnicondylar Spacer Devices for Treatment of Pain or Disability 10/01/2021
ClinicalUplizna® (Inebilizumab-Cdon) 08/01/2021
ReimbursementUrgent Care 06/01/2020
ClinicalVaccines 09/01/2021
ClinicalVagus and External Trigeminal Nerve Stimulation 04/01/2021
ClinicalVertebral Body Tethering for Scoliosis 07/01/2021
ClinicalViltepso® (Viltolarsen) 08/01/2021
ClinicalVirtual Upper Gastrointestinal Endoscopy 12/01/2020
AdministrativeVision Services (Including Refractive Surgery) 01/01/2021
ClinicalVisual Information Processing Evaluation and Orthoptic and Vision Therapy05/01/2021
ClinicalVyepti™ (Eptinezumab-Jjmr) 01/01/2021
ClinicalVyondys 53™ (Golodirsen) 04/01/2021
ClinicalWarming Therapy and Ultrasound Therapy for Wounds 01/01/2021
ClinicalWheelchair Options and Accessories 09/01/2021
ClinicalWheelchair Seating 09/01/2021
ClinicalWhite Blood Cell Colony Stimulating Factors 09/01/2021
ClinicalWhole Exome and Whole Genome Sequencing 10/01/2021
ReimbursementWrong Surgical or Other Invasive Procedures 11/01/2020
ClinicalXiaflex® (Collagenase Clostridium Histolyticum) 04/01/2021
ClinicalXolair® (Omalizumab) 10/01/2021
ClinicalZolgensma® (Onasemnogene Abeparvovec-Xioi) 07/01/2021
ClinicalZulresso™ (Brexanolone) 08/01/2021

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