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) 08/01/2019
ClinicalAblative Treatment for Spinal Pain 02/01/2019
ClinicalAbnormal Uterine Bleeding and Uterine Fibroids 09/01/2019
AdministrativeAbortions (Therapeutic and Elective) 04/01/2019
AdministrativeAccreditation Requirements for Radiology Services 04/01/2019
AdministrativeAcquired Rare Disease Drug Therapy Exception Process 02/01/2019
ClinicalActemra® (Tocilizumab) Injection for Intravenous Infusion 05/01/2019
ReimbursementAcupuncture 11/01/2018
ReimbursementAdd-On Policy 10/01/2018
ReimbursementAdvanced Practice Provider Evaluation and Management Procedures 08/01/2019
ReimbursementAfter Hours and Weekend Care 05/01/2019
ClinicalAlpha1-Proteinase Inhibitors 03/01/2019
ReimbursementAmbulance 08/12/2019
AdministrativeAmbulance Services 06/01/2019
ClinicalApheresis 02/01/2019
AdministrativeAssignment of Benefits & Balance Billing 07/01/2018
ReimbursementAssistant-at-Surgery 03/01/2019
ClinicalAssisted Administration of Clotting Factors, Coagulant Blood Products & Other Hemostatics 07/01/2019
ClinicalAthletic Pubalgia Surgery 06/01/2019
ClinicalAttended Polysomnography for Evaluation of Sleep Disorders 04/01/2019
AdministrativeAutism 10/01/2018
ClinicalAutologous Chondrocyte Transplantation in the Knee 01/01/2019
ReimbursementB Bundle Codes 01/14/2019
ClinicalBalloon Sinus Ostial Dilation 02/01/2019
ClinicalBariatric Surgery11/01/2018
AdministrativeBehavioral Health Services 04/01/2019
ClinicalBenlysta® (Belimumab) 05/01/2019
ReimbursementBilateral Procedures 08/12/2019
ClinicalBlepharoplasty, Blepharoptosis and Brow Ptosis Repair 07/01/2019
ClinicalBone or Soft Tissue Healing and Fusion Enhancement Products 04/01/2019
ClinicalBotulinum Toxins A and B 06/01/2019
ClinicalBreast Imaging for Screening and Diagnosing Cancer 06/01/2019
ClinicalBreast Reconstruction Post Mastectomy 08/09/2019
ClinicalBreast Reduction Surgery 07/01/2019
ClinicalBreast Repair/Reconstruction Not Following Mastectomy 08/09/2019
ClinicalBrineura™ (Cerliponase Alfa) 08/01/2019
ClinicalBronchial Thermoplasty 07/01/2019
ClinicalBuprenorphine (Probuphine® & Sublocade™) 03/01/2019
ClinicalCardiology Procedures Requiring Precertification for eviCore healthcare Arrangement 04/01/2019
ClinicalCardiovascular Disease Risk Tests 01/01/2019
ReimbursementCare Plan Oversight 04/01/2019
ClinicalCarrier Testing for Genetic Diseases 07/01/2019
ClinicalChelation Therapy for Non-Overload Conditions 03/01/2019
ClinicalChemosensitivity and Chemoresistance Assays in Cancer 07/01/2019
ClinicalChromosome Microarray Testing (Non-Oncology Conditions) 07/01/2019
AdministrativeClaims Recovery 02/01/2019
AdministrativeClinical Review 01/01/2019
ClinicalClinical Trials 07/01/2019
ClinicalClotting Factors, Coagulant Blood Products & Other Hemostatics 07/01/2019
ClinicalCochlear Implants 04/01/2019
ClinicalCollagen Crosslinks and Biochemical Markers of Bone Turnover 02/01/2019
ClinicalComplement Inhibitors (Soliris® & Ultomiris™) 09/01/2019
ClinicalComputerized Dynamic Posturography 04/01/2019
ReimbursementConsultation Services 07/01/2017
ClinicalContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes 06/01/2019
AdministrativeContraceptives 07/01/2019
AdministrativeCoordination of Benefits 02/01/2019
ClinicalCore Decompression for Avascular Necrosis 09/01/2019
ClinicalCorneal Hysteresis and Intraocular Pressure Measurement 06/01/2019
ClinicalCosmetic and Reconstructive Procedures 08/01/2019
ReimbursementCo-Surgeon/Team Surgeon 01/01/2019
AdministrativeCredentialing Guidelines: Participation in the eviCore healthcare Network 10/01/2017
ClinicalCrysvita® (Burosumab-Twza) 06/01/2019
ClinicalCytological Examination of Breast Fluids for Cancer Screening or Diagnosis 07/01/2019
ClinicalDeep Brain and Cortical Stimulation 01/01/2019
ClinicalDenosumab (Prolia® & Xgeva®) 05/01/2019
AdministrativeDental and Oral Surgical Procedures 04/01/2019
AdministrativeDiabetes Supply Coverage 06/01/2019
AdministrativeDialysis Services 04/01/2019
AdministrativeDisclosure Policy 09/01/2018
ClinicalDiscogenic Pain Treatment 12/01/2018
ReimbursementDiscontinued Procedure 08/01/2019
ClinicalDrug Coverage Criteria - New and Therapeutic Equivalent Medications 09/01/2019
ClinicalDrug Coverage Guidelines 09/01/2019
ReimbursementDrug Testing 06/01/2019
AdministrativeDurable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements 06/01/2019
ReimbursementDurable Medical Equipment, Orthotics and Prosthetics 02/04/2019
ClinicalElbow Replacement Surgery (Arthroplasty) 04/01/2019
ClinicalElectric Tumor Treatment Field Therapy 01/01/2019
ClinicalElectrical and Ultrasound Bone Growth Stimulators 08/01/2019
ClinicalElectrical Bioimpedance for Cardiac Output Measurement 09/01/2019
ClinicalElectrical Stimulation and Electromagnetic Therapy for Wounds 02/01/2019
ClinicalElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation 07/01/2019
ClinicalElectroencephalographic (EEG) Monitoring and Video Recording 04/01/2019
ClinicalEloctate™ (Antihemophilic Factor (Recombinant), FC Fusion Protein) for Connecticut Lines of Business 03/01/2019
ClinicalEmbolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome 04/01/2019
AdministrativeEmergency Room Visits (Including Coverage for Members Outside of the United States) 06/01/2019
ClinicalEntyvio® (Vedolizumab) 06/01/2019
ClinicalEnzyme Replacement Therapy 06/01/2019
ClinicalEpidural Steroid and Facet Injections for Spinal Pain 05/01/2019
ClinicalEpiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography 12/01/2018
ClinicalErythropoiesis-Stimulating Agents 03/01/2019
ReimbursementEvaluation and Management (E/M) 06/01/2019
ClinicalEvenity™ (Romosozumab-Aqqg) 05/01/2019
ClinicalExondys 51® (Eteplirsen) 04/01/2019
AdministrativeExperimental/Investigational Treatment 02/01/2019
ClinicalExperimental/Investigational Treatment for NJ Plans 02/01/2019
AdministrativeExtended Benefits for Total Disability & Succeeding Carrier for Inpatient Admissions 12/01/2017
ClinicalExtracorporeal Shock Wave Therapy (ESWT) 06/01/2019
ClinicalFecal Calprotectin Testing 04/07/2019
ClinicalFemoroacetabular Impingement Syndrome Treatment 01/01/2019
ClinicalFetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood 05/01/2019
AdministrativeFiling Deadlines for Claims Submissions 11/01/2017
ClinicalFollicle Stimulating Hormone (FSH) Gonadotropins 08/01/2019
AdministrativeFollow-Up Care Rendered in an Emergency Room Site of Service 10/01/2018
AdministrativeFormula & Specialized Food 03/01/2019
ReimbursementFrom - To Date Policy 07/22/2019
ClinicalFunctional Endoscopic Sinus Surgery (FESS) 10/01/2018
ClinicalGamifant™ (Emapalumab-Lzsg) 07/01/2019
ClinicalGastrointestinal Motility Disorders, Diagnosis and Treatment 05/01/2019
ClinicalGender Dysphoria Treatment 09/01/2019
ClinicalGene Expression Tests for Cardiac Indications 11/01/2018
ClinicalGenetic Testing for Hereditary Cancer 07/01/2019
ClinicalGlaucoma Surgical Treatments 08/01/2019
ReimbursementGlobal Days 08/12/2019
ClinicalGonadotropin Releasing Hormone Analogs 04/01/2019
ClinicalGynecomastia Treatment 07/01/2019
ClinicalHearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable 02/01/2019
ClinicalHigh Frequency Chest Wall Compression Devices 01/01/2019
ClinicalHip Resurfacing and Replacement Surgery (Arthroplasty) 04/01/2019
ClinicalHome Health Care 08/01/2019
ClinicalHome Hemodialysis 03/01/2019
ClinicalHome Traction Therapy 05/01/2019
AdministrativeHospice Care 12/01/2017
ClinicalHuman Menopausal Gonadotropins (hMG) 08/01/2019
ClinicalHysterectomy for Benign Conditions 04/01/2019
ClinicalIlaris® (Canakinumab) 03/01/2019
ClinicalIlumya™ (Tildrakizumab-Asmn) 09/01/2019
ClinicalImmune Globulin (IVIG and SCIG) 08/01/2019
ClinicalImmune Globulin - Site of Care 05/01/2019
ClinicalImplantable Beta-Emitting Microspheres for Treatment of Malignant Tumors 01/01/2019
ClinicalImplanted Electrical Stimulator for Spinal Cord 04/01/2019
ReimbursementIncreased Procedural Services 05/01/2019
ClinicalInfertility Diagnosis and Treatment 06/01/2019
ClinicalInfliximab (Remicade®, Inflectra™, Renflexis™) 07/01/2019
ClinicalInjectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines 07/01/2019
ReimbursementInjection and Infusion Services 05/01/2019
AdministrativeIn-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy 06/01/2019
ReimbursementIn-Office Laboratory Testing and Procedures List 08/01/2019
AdministrativeInpatient Maternity Stay and Subsequent Home Nursing 12/01/2017
ClinicalIntraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) 06/01/2019
ReimbursementIntraoperative Neuromonitoring 06/01/2019
ClinicalIntrauterine Fetal Surgery 05/01/2019
ClinicalIntravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease 03/01/2019
ClinicalKnee Replacement Surgery (Arthroplasty), Total and Partial 04/01/2019
ClinicalLaser Interstitial Thermal Therapy 08/01/2019
ClinicalLemtrada (Alemtuzumab) 06/01/2019
ClinicalLight and Laser Therapy 08/01/2019
ClinicalLithotripsy for Salivary Stones 12/01/2018
ClinicalLuxturna™ (Voretigene Neparvovec-Rzyl) 03/01/2019
ClinicalLyme Disease 05/01/2019
ClinicalMacular Degeneration Treatment Procedures 05/01/2019
ClinicalMagnetic Resonance Spectroscopy (MRS) 01/01/2019
ClinicalManipulation Under Anesthesia 02/01/2019
ClinicalManipulative Therapy 05/01/2019
ClinicalMaximum Dosage 07/01/2019
ReimbursementMaximum Frequency Per Day 08/12/2019
AdministrativeMechanical Circulatory Support Device (MCSD) 02/01/2019
ClinicalMechanical Stretching Devices 01/01/2019
AdministrativeMember Administrative Grievance and Appeal (Non UM) Process & Timeframes 12/01/2016
ClinicalMeniscus Implant and Allograft 06/01/2019
ReimbursementMicrosurgery 03/01/2019
ClinicalMifeprex® (Mifepristone) 05/01/2019
ClinicalMinimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) 01/01/2019
ReimbursementModifier Reference 03/01/2019
ReimbursementModifier SU 05/01/2019
ClinicalMolecular Oncology Testing for Cancer Diagnosis, Prognosis and Treatment Decisions 09/01/2019
ClinicalMotorized Spinal Traction 05/01/2019
ReimbursementMultiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures 03/01/2019
ReimbursementMultiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging 08/01/2019
ReimbursementMultiple Procedures Payment Reduction (MPPR) for Medical and Surgical Services 07/01/2019
ClinicalNegative Pressure Wound Therapy 06/01/2019
ClinicalNerve Graft to Restore Erectile Function During Radical Prostatectomy 09/01/2019
ClinicalNeurophysiologic Testing and Monitoring 09/01/2019
ClinicalNeuropsychological Testing Under the Medical Benefit 06/01/2019
ReimbursementNew Patient Visit 10/01/2018
AdministrativeNew York & Connecticut Participating Surgeons Using Non- Participating Providers for Intraoperative Neuro-Monitoring (IONM) 06/01/2018
AdministrativeNewborns 04/01/2018
AdministrativeNon-Participating Provider Consent Form Protocol 03/01/2018
ReimbursementNonphysician Health Care Codes 05/01/2019
ReimbursementNonphysician Health Care Professionals Billing Evaluation and Management Codes 02/01/2019
ClinicalObservation Care 04/01/2019
ReimbursementObservation Care Evaluation and Management Codes 05/01/2019
ReimbursementObstetrical Policy 06/01/2019
ClinicalObstetrical Ultrasonography 04/01/2019
ClinicalObstructive Sleep Apnea Treatment 08/01/2019
ClinicalOccipital Neuralgia and Headache Treatment 04/01/2019
ClinicalOcrevus™ (Ocrelizumab) 08/01/2019
ClinicalOffice Based Program 04/01/2019
ClinicalOff-Label/Unproven Specialty Drug Treatment 07/01/2019
ClinicalOmnibus Codes 05/01/2019
ReimbursementOnce In a Lifetime Procedures 05/01/2019
ReimbursementOne or More Sessions 11/01/2018
ClinicalOnpattro™ (Patisiran) 09/01/2019
ClinicalOrencia® (Abatacept) Injection for Intravenous Infusion 05/01/2019
ClinicalOrthognathic (Jaw) Surgery 07/01/2019
AdministrativeOrthopedic Services 04/01/2019
ClinicalOsteochondral Grafting 01/01/2019
ClinicalOtoacoustic Emissions Testing 06/01/2019
ClinicalOutpatient Cardiac Telemetry 03/01/2019
ClinicalOutpatient Physical & Occupational Therapy for Self-Funded Groups 03/01/2018
ClinicalOutpatient Physical and Occupational Therapy (OptumHealth Care Solutions Arrangement) 07/01/2018
ClinicalOxford's Outpatient Imaging Self-Referral 08/01/2019
ClinicalPanniculectomy and Body Contouring Procedures 09/01/2019
AdministrativePar Gastroenterologists Using Non-Par Anesthesiologists: In-Office & Ambulatory Surgery Centers 05/01/2019
AdministrativePar Surgeons Using Non-Par Assistant Surgeons and Co-Surgeons 01/01/2019
ClinicalParsabiv™ (Etelcalcetide) 06/01/2019
AdministrativeParticipating Provider Laboratory and Pathology Protocol 08/01/2019
ClinicalPectus Deformity Repair 07/01/2019
ReimbursementPediatric and Neonatal Critical and Intensive Care Services 03/01/2019
ClinicalPercutaneous Vertebroplasty and Kyphoplasty 09/01/2019
ClinicalPharmacogenetic Testing 04/01/2019
ReimbursementPhysical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction 05/01/2019
ClinicalPhysical, Occupational (OptumHealth Care Solutions Arrangement) and Speech Therapy including Cognitive/Neuropsychological Rehabilitation for New Jersey Small Group Members 08/01/2018
ReimbursementPhysician Extenders 12/01/2018
ClinicalPlagiocephaly and Craniosynostosis Treatment 12/01/2018
ClinicalPlatelet Derived Growth Factors for Treatment of Wounds 03/01/2019
ClinicalPneumatic Compression Devices 04/01/2019
AdministrativePractitioner/Provider Administrative Claim Reconsideration and Appeal Process 01/01/2019
AdministrativePrecertification Exemptions for Outpatient Services 07/01/2019
ClinicalPreimplantation Genetic Testing 06/01/2019
ClinicalPreventive Care Services 07/01/2019
ReimbursementPreventive Medicine and Screening 06/01/2019
ClinicalPrivate Duty Nursing (PDN) Services 08/01/2019
ReimbursementProcedure and Place of Service 06/01/2019
ReimbursementProlonged Services 03/01/2019
ClinicalProlotherapy for Musculoskeletal Indications 05/01/2019
ClinicalProsthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs 08/01/2019
ClinicalProvider Administered Drugs – Site of Care 07/01/2019
ClinicalRadiation Therapy Procedures Requiring Precertification for eviCore heathcare Arrangement 03/01/2019
ClinicalRadicava™ (Edaravone) 05/01/2019
ClinicalRadiology Procedures Requiring Precertification for eviCore heathcare Arrangement 07/01/2019
ClinicalRadiopharmaceuticals and Contrast Media 01/01/2019
ReimbursementReduced Services 03/01/2019
AdministrativeReferrals 04/01/2018
ReimbursementReimbursement for Comprehensive and Component CPT Codes 03/01/2018
ReimbursementReplacement Codes 03/01/2019
ClinicalRepository Corticotropin Injection (H.P. Acthar Gel®) 06/01/2019
AdministrativeRequests for In-Network Exceptions 09/01/2018
ClinicalRespiratory Interleukins (Cinqair®, Fasenra®, and Nucala®) 03/01/2019
ClinicalReview at Launch for New to Market Medications 03/01/2019
ClinicalRhinoplasty and Other Nasal Surgeries 06/01/2019
ClinicalRituximab (Rituxan® & Truxima®) 07/01/2019
ReimbursementRobotic Assisted Surgery 02/01/2019
ClinicalRoutine Foot Care 05/01/2019
ReimbursementSame Day/Same Service 07/01/2019
ClinicalSandostatin LAR® Depot (Octreotide Acetate) 06/01/2019
ClinicalSensory Integration Therapy and Auditory Integration Training 09/01/2019
ReimbursementServices and Modifiers Not Reimbursable to Healthcare Professionals 01/01/2019
AdministrativeServices Requiring Prior Authorization 09/01/2019
ClinicalShoulder Replacement Surgery (Arthroplasty) 04/01/2019
ClinicalSimponi® Aria (Golimumab) Injection for Intravenous Infusion 05/01/2019
ReimbursementSite of Service Differential 01/01/2019
ClinicalSite of Service Guidelines for Certain Outpatient Surgical Procedures 05/01/2018
AdministrativeSkilled Care and Custodial Care Services 08/01/2019
ClinicalSkin and Soft Tissue Substitutes 08/01/2019
ClinicalSodium Hyaluronate 06/01/2019
ReimbursementSpecialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting 04/01/2019
AdministrativeSpeech Therapy and Early Intervention Programs/Birth to Three 10/01/2018
ClinicalSpinraza™ (Nusinersen) 06/01/2019
ReimbursementSplit Surgical Package 07/01/2018
ClinicalSpravato™ (Esketamine) 06/01/2019
ReimbursementStandby Services 04/01/2018
ClinicalStelara® (Ustekinumab) 05/01/2019
ReimbursementSupply Policy 08/12/2019
ClinicalSurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins 09/01/2019
ClinicalSurgical Treatment for Spine Pain 04/01/2019
ClinicalSynagis® (Palivizumab) 08/01/2019
ReimbursementT Status Codes 07/01/2019
ReimbursementTelehealth and Telemedicine 04/01/2019
ClinicalTemporomandibular Joint Disorders 04/01/2019
ClinicalThermography 04/01/2019
ReimbursementTime Span Codes 03/01/2019
AdministrativeTimeframe Standards for Benefit Administrative Initial Decisions 11/01/2018
AdministrativeTimeframe Standards for Utilization Management (UM) Initial Decisions 11/01/2018
ClinicalTotal Artificial Disc Replacement for the Spine 07/01/2019
ClinicalTotal Artificial Heart 09/01/2019
ClinicalTranscatheter Heart Valve Procedures 02/01/2019
ClinicalTranscranial Magnetic Stimulation 02/01/2019
ClinicalTranspupillary Thermotherapy 06/01/2019
ClinicalTrogarzo™ (Ibalizumab-Uiyk) 04/01/2019
ClinicalUmbilical Cord Blood Harvesting and Storage for Future Use 07/01/2019
ClinicalUnicondylar Spacer Devices for Treatment of Pain or Disability 08/01/2019
ReimbursementUrgent Care 04/01/2019
ClinicalVaccines 06/01/2019
ClinicalVagus Nerve Stimulation 05/01/2019
ClinicalVirtual Upper Gastrointestinal Endoscopy 09/01/2019
AdministrativeVision Services (Including Refractive Surgery) 09/01/2018
ClinicalVisual Information Processing Evaluation and Orthoptic and Vision Therapy01/01/2019
ClinicalWarming Therapy and Ultrasound Therapy for Wounds 01/01/2019
ClinicalWhite Blood Cell Colony Stimulating Factors 07/01/2019
ClinicalWhole Exome and Whole Genome Sequencing 09/01/2019
ReimbursementWrong Surgical or Other Invasive Procedures 06/01/2019
ClinicalXolair® (Omalizumab) 09/01/2019
ClinicalZolgensma® (Onasemnogene Abeparvovec-Xioi) 07/01/2019
ClinicalZulresso™ (Brexanolone) 08/01/2019

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