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) 10/01/2016
ClinicalAblative Treatment for Spinal Pain 01/01/2017
ClinicalAbnormal Uterine Bleeding and Uterine Fibroids 04/01/2017
AdministrativeAbortions (Therapeutic and Elective) 10/01/2016
Administrative Accreditaiton Requirements for Radiology Services 07/01/2016
AdministrativeAcquired Rare Disease Drug Therapy Exception Process 01/01/2017
ClinicalActemra® (Tocilizumab) Injection for Intravenous Infusion 05/01/2017
ReimbursementAdd-On Policy 06/01/2016
ReimbursementAfter Hours and Weekend Care 03/01/2017
ReimbursementAmbulance 05/01/2017
ClinicalAnemia Drugs: Darbepoetin Alfa, Epoetin Alfa, and Methoxy Polyethylene Glycol-Epoetin Beta 10/01/2016
ClinicalApheresis 08/01/2016
AdministrativeAssignment of Benefits & Balance Billing 11/01/2016
ReimbursementAssistant Surgeon 04/01/2017
ClinicalAssisted Administration of Clotting Factors and Coagulant Blood Products 02/01/2017
ClinicalAthletic Pubalgia Surgery 08/01/2016
ClinicalAttended Polysomnography for Evaluation of Sleep Disorders 04/01/2017
AdministrativeAutism 02/01/2017
ClinicalAutologous Chondrocyte Transplantation in the Knee 11/01/2016
ReimbursementB Bundle Codes 01/09/2017
ClinicalBalloon Sinus Ostial Dilation 12/01/2016
ClinicalBariatric Surgery 03/01/2017
ClinicalBehavioral Health Services 02/01/2017
ReimbursementBilateral Procedures 03/13/2017
ClinicalBlepharoplasty, Blepharoptosis and Brow Ptosis Repair 04/01/2017
ClinicalBone or Soft Tissue Healing and Fusion Enhancement Products 04/01/2017
ClinicalBotulinum Toxins A and B 01/01/2017
ClinicalBreast Imaging for Screening and Diagnosing Cancer 04/01/2017
ClinicalBreast Reconstruction Post Mastectomy 01/01/2017
ClinicalBreast Reduction Surgery 04/01/2017
ClinicalBreast Repair/Reconstruction Not Following Mastectomy 01/01/2017
ClinicalBronchial Thermoplasty 08/01/2016
ClinicalCardiology Procedures Requiring Precertification for eviCore healthcare Arrangement 02/01/2017
ClinicalCardiovascular Disease Risk Tests 01/01/2017
ReimbursementCare Plan Oversight 06/01/2016
ClinicalChelation Therapy for Non-Overload Conditions 05/01/2017
ClinicalChemosensitivity and Chemoresistance Assays in Cancer 12/01/2016
ClinicalChromosome Microarray Testing 02/01/2017
AdministrativeClaims Recovery 11/01/2016
AdministrativeClinical Review Policy 08/01/2016
ClinicalClinical Trials 01/01/2017
ClinicalClotting Factors and Coagulant Blood Products 02/01/2017
ClinicalCochlear Implants 05/01/2016
ClinicalCollagen Crosslinks and Biochemical Markers of Bone Turnover 04/01/2017
ClinicalComputerized Dynamic Posturography 07/01/2016
ReimbursementConsultation Services 07/01/2016
ClinicalContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes 04/01/2017
ClinicalContraceptives 01/01/2017
AdministrativeCoordination of Benefits 12/01/2016
ClinicalCore Decompression for Avascular Necrosis 11/01/2016
ClinicalCorneal Hysteresis and Intraocular Pressure Measurement 07/01/2016
ClinicalCosmetic and Reconstructive Procedures 09/01/2016
ReimbursementCo-Surgeon/Team Surgeon 02/01/2017
AdministrativeCredentialing Guidelines: Participation in the eviCore healthcare Network 07/01/2016
ClinicalCytological Examination of Breast Fluids for Cancer Screening 04/01/2017
ClinicalDeep Brain and Cortical Stimulation 03/01/2017
AdministrativeDental and Oral Surgical Procedures 03/01/2017
AdministrativeDiabetes Supply Coverage for Commercial Plans (Including New Jersey Small Group Plans) 03/01/2017
AdministrativeDialysis Services 01/01/2017
AdministrativeDisclosure Policy 07/01/2016
ClinicalDiscogenic Pain Treatment 01/01/2017
ReimbursementDiscontinued Procedure 07/01/2016
ClinicalDrug Coverage Criteria - New and Therapeutic Equivalent Medications 05/01/2017
ClinicalDrug Coverage Guidelines 05/01/2017
AdministrativeDurable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements 05/01/2017
ReimbursementDurable Medical Equipment, Orthotics and Prosthetics Multiple Frequency 01/09/2017
ClinicalElbow Replacement Surgery (Arthroplasty) 04/01/2017
ClinicalElectric Tumor Treatment Field Therapy 01/01/2017
ClinicalElectrical and Ultrasound Bone Growth Stimulators 04/01/2017
ClinicalElectrical Bioimpedance for Cardiac Output Measurement 09/01/2016
ClinicalElectrical Stimulation and Electromagnetic Therapy for Wounds 02/01/2017
ClinicalElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation 02/01/2017
ClinicalEloctate™ (Antihemophilic Factor (Recombinant), FC Fusion Protein) for Connecticut Lines of Business 02/01/2017
ClinicalEmbolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome 05/01/2017
AdministrativeEmergency Room Visits (Including Coverage for Members Outside of the United States) 02/01/2017
ClinicalEntyvio® (Vedolizumab) 02/01/2017
ClinicalEpidural Steroid and Facet Injections for Spinal Pain 04/01/2017
ClinicalEpiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography 01/01/2017
ReimbursementEvaluation and Management (E/M) 11/01/2016
ClinicalExondys 51™ (Eteplirsen) 04/01/2017
AdministrativeExperimental/Investigational Treatment 02/01/2017
AdministrativeExperimental/Investigational Treatment for NJ Plans 02/01/2017
AdministrativeExtended Benefits for Total Disability (Including Succeeding Carrier for Inpatient Admissions) 02/01/2017
ClinicalExtracorporeal Shock Wave Therapy (ESWT) 01/01/2017
ClinicalFecal Calprotectin Testing 03/01/2017
ClinicalFecal DNA Testing 05/01/2017
ClinicalFemoroacetabular Impingement Syndrome Treatment 01/01/2017
ClinicalFetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood 01/01/2017
AdministrativeFiling Deadlines for Claims Submissions 12/01/2016
ClinicalFollicle Stimulating Hormone (FSH) Gonadotropins 11/01/2016
AdministrativeFormula & Specialized Food 03/01/2017
ReimbursementFrom - To Date Policy 01/01/2017
ClinicalFunctional Endoscopic Sinus Surgery (FESS) 11/01/2016
ClinicalGait Analysis 06/01/2016
ClinicalGastrointestinal Motility Disorders, Diagnosis and Treatment 08/01/2016
ClinicalGender Dysphoria Treatment 01/01/2017
ClinicalGene Expression Tests 05/01/2017
ClinicalGenetic Testing 05/01/2017
ClinicalGenetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC) 04/01/2017
ClinicalGlaucoma Surgical Treatments 05/01/2017
ReimbursementGlobal Days 05/01/2017
ClinicalGonadotropin Releasing Hormone Analogs 02/01/2017
ClinicalGynecomastia Treatment 07/01/2016
ClinicalHearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable 02/01/2017
ClinicalHelicobacter Pylori Serology Testing 02/01/2017
ClinicalHigh Frequency Chest Wall Compression Devices 11/01/2016
ClinicalHip Replacement Surgery (Arthroplasty) 04/01/2017
ClinicalHip Resurfacing Arthroplasty 12/01/2016
ClinicalHome Health Care 03/01/2017
ClinicalHome Hemodialysis 04/01/2017
ClinicalHome Traction Therapy 08/01/2016
AdministrativeHospice Care 01/01/2017
ClinicalHuman Menopausal Gonadotropins (hMG) 11/01/2016
ClinicalHysterectomy for Benign Conditions 04/01/2017
ClinicalImmune Globulin (IVIG and SCIG) 02/01/2017
ClinicalImmune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion 04/01/2017
ClinicalImplantable Beta-Emitting Microspheres for Treatment of Malignant Tumors 01/01/2017
ClinicalImplanted Electrical Stimulator for Spinal Cord 04/01/2017
ClinicalIn Utero Fetal Surgery 07/01/2016
ReimbursementIncreased Procedural Services 03/01/2017
ClinicalInfertility Diagnosis and Treatment 02/01/2017
ClinicalInfliximab (Remicade® and Inflectra™) 04/01/2017
ClinicalInjectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines 01/01/2017
ReimbursementInjection and Infusion Services 04/01/2017
ClinicalIn-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy 02/01/2017
ReimbursementIn-Office Laboratory Testing and Procedures List 05/01/2017
AdministrativeInpatient Maternity Stay and Subsequent Home Nursing 12/01/2016
ClinicalIntraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) 07/01/2016
ClinicalIntravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease 02/01/2017
ClinicalLemtrada (Alemtuzumab) 10/01/2016
ClinicalLight and Laser Therapy for Cutaneous Lesions and Pilonidal Disease 10/01/2016
ClinicalLithotripsy for Salivary Stones 10/01/2016
ClinicalLyme Disease 11/01/2016
ClinicalMacular Degeneration Treatment Procedures 07/01/2016
ClinicalMagnetic Resonance Spectroscopy (MRS) 09/01/2016
ClinicalMagnetoencephalography and Magnetic Source Imaging for Specific Neurological Applications 07/01/2016
ClinicalManipulation Under Anesthesia 04/01/2017
ClinicalManipulative Therapy 06/01/2016
ClinicalMaximum Dosage Policy 02/01/2017
ReimbursementMaximum Frequency Per Day 03/13/2017
AdministrativeMechanical Circulatory Support Device (MCSD) 02/01/2017
ClinicalMechanical Stretching Devices 03/01/2017
AdministrativeMember Administrative Grievance and Appeal (Non UM) Process & Timeframes 12/01/2016
ClinicalMeniscus Implant and Allograft 08/01/2016
ReimbursementMicrosurgery 10/01/2016
ClinicalMifeprex® (Mifepristone, RU-486) 08/01/2016
ClinicalMinimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) 01/01/2017
ReimbursementModifier Reference 11/01/2016
ReimbursementModifier SU 03/01/2017
ClinicalMolecular Profiling to Guide Cancer Treatment 08/01/2016
ClinicalMotorized Spinal Traction 08/01/2016
ReimbursementMultiple Imaging Rules 05/01/2017
ReimbursementMultiple Procedures05/01/2017
ClinicalNerve Graft to Restore Erectile Function During Radical Prostatectomy 10/01/2016
ClinicalNeurophysiologic Testing 01/01/2017
ClinicalNeuropsychological Testing Under the Medical Benefit 10/01/2016
ReimbursementNew Patient Visit 06/01/2016
AdministrativeNew York Participating Provider Laboratory & Pathology Protocol 05/01/2017
AdministrativeNew York Providers Protocols and Guidelines 06/01/2016
AdministrativeNewborns 11/01/2016
AdministrativeNon-Participating Provider Consent Form Protocol 01/01/2017
ReimbursementNonphysician Health Care Codes 03/01/2017
ReimbursementNonphysician Health Care Professionals Billing Evaluation and Management Codes 01/01/2017
ClinicalObservation Care 04/01/2017
ReimbursementObservation Care Evaluation and Management Codes 03/01/2017
ReimbursementObstetrical Policy 02/01/2017
ClinicalObstetrical Ultrasonography 02/01/2017
ClinicalObstructive Sleep Apnea Treatment 04/01/2017
ClinicalOccipital Neuralgia and Headache Treatment 01/01/2017
ClinicalOcrevus® (Ocrelizumab) 01/01/2017
ClinicalOffice Based Program 04/01/2017
ClinicalOff-Label/Unproven Specialty Drug Treatment 04/01/2017
ClinicalOmnibus Codes 04/01/2017
ReimbursementOnce In a Lifetime Procedures 03/01/2017
ReimbursementOne or More Sessions 01/09/2017
ClinicalOrencia® (Abatacept) Injection for Intravenous Infusion 05/01/2017
ClinicalOrthognathic (Jaw) Surgery 04/01/2017
AdministrativeOrthopedic Services 04/01/2017
ClinicalOsteochondral Grafting of Knee 11/01/2016
ClinicalOtoacoustic Emissions Testing 05/01/2017
ClinicalOutpatient Cardiovascular Telemetry 03/01/2017
ClinicalOutpatient Physical & Occupational Therapy for Self-Funded Groups 02/01/2017
ClinicalOutpatient Physical and Occupational Therapy (OptumHealth Care Solutions Arrangement) 02/01/2017
ClinicalOxford's Outpatient Imaging Self-Referral Policy 02/01/2017
ClinicalPanniculectomy and Body Contouring Procedures 04/01/2017
AdministrativePar Gastroenterologists Using Non-Par Anesthesiologists: In-Office & Ambulatory Surgery Centers 05/01/2017
ClinicalPectus Deformity Repair 10/01/2016
ReimbursementPediatric and Neonatal Critical and Intensive Care Services 09/01/2016
ClinicalPercutaneous Vertebroplasty and Kyphoplasty 12/01/2016
ReimbursementPhysical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction 05/01/2017
ClinicalPhysical, Occupational (OptumHealth Care Solutions Arrangement) and Speech Therapy including Cognitive/Neuropsychological Rehabilitation for New Jersey Small Group Members 02/01/2017
ReimbursementPhysician Extenders 04/01/2017
ClinicalPlagiocephaly and Craniosynostosis Treatment 10/01/2016
ClinicalPlatelet Derived Growth Factors for Treatment of Wounds 04/01/2017
ClinicalPneumatic Compression Devices 04/01/2017
AdministrativePractitioner/Provider Administrative Claim Reconsideration and Appeal Process 12/01/2016
AdministrativePrecertification Exemptions for Outpatient Services 05/01/2017
ClinicalPreterm Labor Management 08/01/2016
ClinicalPreventive Care Services 04/01/2017
ReimbursementPreventive Medicine and Screening 04/01/2017
ClinicalPrivate Duty Nursing Services (PDN) 09/01/2016
ClinicalProbuphine® (Buprenorphine) 02/01/2017
ReimbursementProcedure and Place of Service 05/01/2017
ReimbursementProlonged Services 11/01/2016
ClinicalProlotherapy for Musculoskeletal Indications 06/01/2016
ClinicalProsthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs 02/01/2017
ClinicalRadiation Therapy Procedures Requiring Precertification for eviCore heathcare Arrangement 03/01/2017
ClinicalRadiology Procedures Requiring Precertification for eviCore heathcare Arrangement 02/01/2017
ReimbursementRadiopharmaceuticals and Contrast Media 01/01/2017
ReimbursementReduced Services 11/01/2016
AdministrativeReferrals 05/01/2017
AdministrativeRefractive Surgeries 03/01/2017
ReimbursementReimbursement for Comprehensive and Component CPT Codes 05/01/2017
ReimbursementReplacement Codes 03/01/2017
ClinicalRepository Corticotropin Injection (H.P. Acthar Gel®) 02/01/2017
AdministrativeRequests for In-Network Exceptions 05/01/2015
ClinicalRespiratory Interleukins (IL) Policy 02/01/2017
ClinicalRhinoplasty and Other Nasal Surgeries 04/01/2017
ClinicalRituxan® (Rituximab) 10/01/2016
ReimbursementRobotic-Assisted Surgery 11/01/2016
ClinicalRoutine Foot Care 01/01/2017
ReimbursementSame Day/Same Service 07/01/2016
ClinicalSandostatin LAR® Depot (Octreotide Acetate) 01/01/2017
ClinicalSensory Integration Therapy and Auditory Integration Training 11/01/2016
ReimbursementServices and Modifiers Not Reimbursable to Healthcare Professionals 05/01/2017
AdministrativeServices Requiring Prior Authorization 05/01/2017
ClinicalShoulder Replacement Surgery (Arthroplasty) 04/01/2017
ClinicalSimponi® Aria™ (Golimumab) Injection for Intravenous Infusion 12/01/2016
AdministrativeSite of Service Differential 01/01/2017
ClinicalSite of Service Guidelines for Certain Outpatient Surgical Procedures 10/01/2016
AdministrativeSkilled Care and Custodial Care Services 09/01/2016
ClinicalSodium Hyaluronate 01/01/2017
ClinicalSoliris® (Eculizumab) 02/01/2017
ClinicalSpecialty Medication Administration - Site of Care Review Guidelines 04/01/2017
AdministrativeSpeech Therapy and Early Intervention Programs/Birth to Three 02/01/2017
ClinicalSpinraza™ (Nusinersen) 05/01/2017
ReimbursementSplit Surgical Package 07/01/2016
ReimbursementStandby Services 03/01/2017
ClinicalStanding Systems and Gait Trainers 12/01/2016
ClinicalStelara® (Ustekinumab) 02/01/2017
ReimbursementSupply Policy 02/01/2017
ClinicalSurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins 03/01/2017
ClinicalSurgical Treatment for Spine Pain 04/01/2017
ClinicalSynagis® (Palivizumab) 12/01/2016
ReimbursementT Status Codes 04/01/2017
ReimbursementTelemedicine 05/01/2017
ClinicalTemporomandibular Joint Disorders 04/01/2017
ClinicalThermal Capsulorrhaphy/Thermal Shrinkage Therapy 04/01/2017
ClinicalThermography 05/01/2017
ReimbursementTime Span Codes 02/01/2017
AdministrativeTimeframe Standards for Benefit Administrative Initial Decisions 02/01/2017
AdministrativeTimeframe Standards for Utilization Management (UM) Initial Decisions 05/01/2017
ClinicalTotal Artificial Disc Replacement for Spine 04/01/2017
ClinicalTotal Artificial Heart 11/01/2016
ClinicalTotal Knee Replacement Surgery (Arthroplasty) 04/01/2017
ClinicalTranscatheter Heart Valve Procedures 01/01/2017
ClinicalTranscranial Magnetic Stimulation 03/01/2017
AdministrativeTransportation Services 01/01/2017
ClinicalTranspupillary Thermotherapy 07/01/2016
ClinicalUmbilical Cord Blood Harvesting and Storage for Future Use 08/01/2016
ClinicalUnicondylar Spacer Devices for Treatment of Pain or Disability 10/01/2016
ReimbursementUrgent Care 08/01/2016
ClinicalVaccines 08/01/2016
ClinicalVagus Nerve Stimulation 01/01/2017
ClinicalVirtual Upper Gastrointestinal Endoscopy 11/01/2016
AdministrativeVision Services 01/01/2017
ClinicalVisual Information Processing Evaluation and Orthoptic and Vision Therapy 11/01/2016
ClinicalWarming Therapy and Ultrasound Therapy for Wounds 11/01/2016
ClinicalWearable Cardioverter-Defibrillators 04/01/2017
ReimbursementWrong Surgical or Other Invasive Procedures 03/01/2017
ClinicalXolair® (Omalizumab) 10/01/2016

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