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) 03/01/2019
ClinicalAblative Treatment for Spinal Pain 02/01/2019
ClinicalAbnormal Uterine Bleeding and Uterine Fibroids 02/01/2019
AdministrativeAbortions (Therapeutic and Elective) 10/01/2018
AdministrativeAccreditation Requirements for Radiology Services 12/01/2018
AdministrativeAcquired Rare Disease Drug Therapy Exception Process 02/01/2019
ClinicalActemra® (Tocilizumab) Injection for Intravenous Infusion 03/01/2019
ReimbursementAcupuncture 11/01/2018
ReimbursementAdd-On Policy 10/01/2018
ReimbursementAfter Hours and Weekend Care 10/01/2018
ClinicalAlpha1-Proteinase Inhibitors 03/01/2019
ReimbursementAmbulance 02/04/2019
AdministrativeAmbulance Services 06/01/2018
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 03/01/2019
ClinicalAthletic Pubalgia Surgery 12/01/2018
ClinicalAttended Polysomnography for Evaluation of Sleep Disorders 02/01/2019
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 02/01/2019
ClinicalBenlysta® (Belimumab) 03/01/2019
ReimbursementBilateral Procedures 01/14/2019
ClinicalBlepharoplasty, Blepharoptosis and Brow Ptosis Repair 04/01/2018
ClinicalBone or Soft Tissue Healing and Fusion Enhancement Products 01/01/2019
ClinicalBotulinum Toxins A and B 03/01/2019
ClinicalBreast Imaging for Screening and Diagnosing Cancer 03/01/2019
ClinicalBreast Reconstruction Post Mastectomy 12/01/2018
ClinicalBreast Reduction Surgery 10/01/2018
ClinicalBreast Repair/Reconstruction Not Following Mastectomy 01/01/2019
ClinicalBrineura™ (Cerliponase Alfa) 03/01/2019
ClinicalBronchial Thermoplasty 12/01/2018
ClinicalBuprenorphine (Probuphine® & Sublocade™) 03/01/2019
ClinicalCardiology Procedures Requiring Precertification for eviCore healthcare Arrangement 01/01/2019
ClinicalCardiovascular Disease Risk Tests 01/01/2019
ReimbursementCare Plan Oversight 01/01/2019
ClinicalCarrier Testing for Genetic Diseases 01/01/2019
ClinicalChelation Therapy for Non-Overload Conditions 03/01/2019
ClinicalChemosensitivity and Chemoresistance Assays in Cancer 01/01/2019
ClinicalChromosome Microarray Testing (Non-Oncology Conditions) 10/01/2018
AdministrativeClaims Recovery 02/01/2019
AdministrativeClinical Review 01/01/2019
ClinicalClinical Trials 03/01/2019
ClinicalClotting Factors, Coagulant Blood Products & Other Hemostatics 03/01/2019
ClinicalCochlear Implants 01/01/2019
ClinicalCollagen Crosslinks and Biochemical Markers of Bone Turnover 02/01/2019
ClinicalComputerized Dynamic Posturography 12/01/2018
ReimbursementConsultation Services 07/01/2017
ClinicalContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes 10/01/2018
AdministrativeContraceptives 08/01/2018
AdministrativeCoordination of Benefits 02/01/2019
ClinicalCore Decompression for Avascular Necrosis 12/01/2018
ClinicalCorneal Hysteresis and Intraocular Pressure Measurement 12/01/2018
ClinicalCosmetic and Reconstructive Procedures 07/01/2018
ReimbursementCo-Surgeon/Team Surgeon 01/01/2019
AdministrativeCredentialing Guidelines: Participation in the eviCore healthcare Network 10/01/2017
ClinicalCrysvita® (Burosumab-Twza) 03/01/2019
ClinicalCytological Examination of Breast Fluids for Cancer Screening 12/01/2018
ClinicalDeep Brain and Cortical Stimulation 01/01/2019
ClinicalDenosumab (Prolia® & Xgeva®) 03/01/2019
AdministrativeDental and Oral Surgical Procedures 12/01/2018
AdministrativeDiabetes Supply Coverage for Commercial Plans (Including New Jersey Small Group Plans) 03/01/2017
AdministrativeDialysis Services 12/01/2017
AdministrativeDisclosure Policy 09/01/2018
ClinicalDiscogenic Pain Treatment 12/01/2018
ReimbursementDiscontinued Procedure 07/01/2018
ClinicalDrug Coverage Criteria - New and Therapeutic Equivalent Medications 03/01/2019
ClinicalDrug Coverage Guidelines 03/01/2019
ReimbursementDrug Testing 01/01/2019
AdministrativeDurable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements 02/01/2019
ReimbursementDurable Medical Equipment, Orthotics and Prosthetics 02/04/2019
ClinicalElbow Replacement Surgery (Arthroplasty) 10/01/2018
ClinicalElectric Tumor Treatment Field Therapy 01/01/2019
ClinicalElectrical and Ultrasound Bone Growth Stimulators 10/01/2018
ClinicalElectrical Bioimpedance for Cardiac Output Measurement 12/01/2018
ClinicalElectrical Stimulation and Electromagnetic Therapy for Wounds 02/01/2019
ClinicalElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation 02/01/2019
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 12/01/2018
AdministrativeEmergency Room Visits (Including Coverage for Members Outside of the United States) 02/01/2017
ClinicalEntyvio® (Vedolizumab) 03/01/2019
ClinicalEnzyme Replacement Therapy 03/01/2019
ClinicalEpidural Steroid and Facet Injections for Spinal Pain 11/01/2018
ClinicalEpiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography 12/01/2018
ClinicalErythropoiesis-Stimulating Agents 03/01/2019
ReimbursementEvaluation and Management (E/M) 03/01/2018
ClinicalExondys 51® (Eteplirsen) 03/01/2019
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) 01/01/2019
ClinicalFecal Calprotectin Testing 11/01/2018
ClinicalFemoroacetabular Impingement Syndrome Treatment 01/01/2019
ClinicalFetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood 03/01/2019
AdministrativeFiling Deadlines for Claims Submissions 11/01/2017
ClinicalFollicle Stimulating Hormone (FSH) Gonadotropins 03/01/2019
AdministrativeFollow-Up Care Rendered in an Emergency Room Site of Service 10/01/2018
AdministrativeFormula & Specialized Food 03/01/2019
ReimbursementFrom - To Date Policy 02/01/2019
ClinicalFunctional Endoscopic Sinus Surgery (FESS) 10/01/2018
ClinicalGamifant™ (Emapalumab-Lzsg) 03/01/2019
ClinicalGastrointestinal Motility Disorders, Diagnosis and Treatment 12/01/2018
ClinicalGene Expression Tests for Cardiac Indications 11/01/2018
ClinicalGenetic Testing for Hereditary Cancer 01/01/2019
ClinicalGlaucoma Surgical Treatments 11/01/2018
ReimbursementGlobal Days 01/14/2019
ClinicalGonadotropin Releasing Hormone Analogs 03/01/2019
ClinicalGynecomastia Treatment 06/01/2018
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) 12/01/2018
ClinicalHome Health Care 01/01/2019
ClinicalHome Hemodialysis 03/01/2019
ClinicalHome Traction Therapy 12/01/2018
AdministrativeHospice Care 12/01/2017
ClinicalHuman Menopausal Gonadotropins (hMG) 03/01/2019
ClinicalHysterectomy for Benign Conditions 10/01/2018
ClinicalIlaris® (Canakinumab) 03/01/2019
ClinicalIlumya™ (Tildrakizumab-Asmn) 03/01/2019
ClinicalImmune Globulin (IVIG and SCIG) 03/01/2019
ClinicalImmune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion 04/01/2018
ClinicalImplantable Beta-Emitting Microspheres for Treatment of Malignant Tumors 01/01/2019
ClinicalImplanted Electrical Stimulator for Spinal Cord 01/01/2019
ReimbursementIncreased Procedural Services 01/01/2019
ClinicalInfertility Diagnosis and Treatment 01/01/2019
ClinicalInfliximab (Remicade®, Inflectra™, Renflexis™) 03/01/2019
ClinicalInjectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines 03/01/2019
ReimbursementInjection and Infusion Services 01/14/2019
AdministrativeIn-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy 09/01/2018
ReimbursementIn-Office Laboratory Testing and Procedures List 01/01/2018
AdministrativeInpatient Maternity Stay and Subsequent Home Nursing 12/01/2017
ClinicalIntraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) 01/01/2019
ReimbursementIntraoperative Neuromonitoring 01/01/2019
ClinicalIntrauterine Fetal Surgery 12/01/2018
ClinicalIntravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease 03/01/2019
ClinicalLaser Interstitial Thermal Therapy 12/01/2018
ClinicalLemtrada (Alemtuzumab) 03/01/2019
ClinicalLight and Laser Therapy for Cutaneous Lesions and Pilonidal Disease 02/01/2019
ClinicalLithotripsy for Salivary Stones 12/01/2018
ClinicalLuxturna™ (Voretigene Neparvovec-Rzyl) 03/01/2019
ClinicalLyme Disease 12/01/2018
ClinicalMacular Degeneration Treatment Procedures 01/01/2019
ClinicalMagnetic Resonance Spectroscopy (MRS) 01/01/2019
ClinicalManipulation Under Anesthesia 02/01/2019
ClinicalManipulative Therapy 11/01/2018
ClinicalMaximum Dosage 03/01/2019
ReimbursementMaximum Frequency Per Day 02/01/2019
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 01/01/2019
ReimbursementMicrosurgery 03/01/2019
ClinicalMifeprex® (Mifepristone) 03/01/2019
ClinicalMinimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) 01/01/2019
ReimbursementModifier Reference 03/01/2019
ReimbursementModifier SU 04/01/2018
ClinicalMolecular Oncology Testing for Cancer Diagnosis, Prognosis and Treatment Decisions 01/01/2019
ClinicalMotorized Spinal Traction 12/01/2018
ReimbursementMultiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures 03/01/2019
ReimbursementMultiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging 03/01/2019
ReimbursementMultiple Procedures Payment Reduction (MPPR) for Medical and Surgical Services 02/01/2019
ClinicalNegative Pressure Wound Therapy 02/01/2019
ClinicalNerve Graft to Restore Erectile Function During Radical Prostatectomy 12/01/2018
ClinicalNeurophysiologic Testing and Monitoring 02/01/2019
ClinicalNeuropsychological Testing Under the Medical Benefit 03/01/2019
ReimbursementNew Patient Visit 10/01/2018
AdministrativeNew York & Connecticut Participating Surgeons Using Non- Participating Providers for Intraoperative Neuro-Monitoring (IONM) 06/01/2018
AdministrativeNew York Participating Provider Laboratory & Pathology Protocol 05/01/2017
AdministrativeNewborns 04/01/2018
AdministrativeNon-Participating Provider Consent Form Protocol 03/01/2018
ReimbursementNonphysician Health Care Codes 04/01/2018
ReimbursementNonphysician Health Care Professionals Billing Evaluation and Management Codes 02/01/2019
ClinicalObservation Care 04/01/2018
ReimbursementObservation Care Evaluation and Management Codes 04/01/2018
ReimbursementObstetrical Policy 11/12/2018
ClinicalObstetrical Ultrasonography 10/01/2018
ClinicalObstructive Sleep Apnea Treatment 01/01/2019
ClinicalOccipital Neuralgia and Headache Treatment 02/01/2019
ClinicalOcrevus™ (Ocrelizumab) 03/01/2019
ClinicalOffice Based Program 12/01/2018
ClinicalOff-Label/Unproven Specialty Drug Treatment 03/01/2019
ClinicalOmnibus Codes 02/01/2019
ReimbursementOnce In a Lifetime Procedures 05/01/2018
ReimbursementOne or More Sessions 11/01/2018
ClinicalOnpattro™ (Patisiran) 03/01/2019
ClinicalOrencia® (Abatacept) Injection for Intravenous Infusion 03/01/2019
ClinicalOrthognathic (Jaw) Surgery 10/01/2018
AdministrativeOrthopedic Services 10/01/2018
ClinicalOsteochondral Grafting 01/01/2019
ClinicalOtoacoustic Emissions Testing 10/01/2018
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 01/01/2019
ClinicalPanniculectomy and Body Contouring Procedures 10/01/2018
AdministrativePar Gastroenterologists Using Anesthesiologists: In-Office & Ambulatory Surgery Centers 05/01/2017
AdministrativePar Surgeons Using Non-Par Assistant Surgeons and Co-Surgeons 01/01/2019
ClinicalParsabiv™ (Etelcalcetide) 03/01/2019
ClinicalPectus Deformity Repair 08/01/2018
ReimbursementPediatric and Neonatal Critical and Intensive Care Services 03/01/2019
ClinicalPercutaneous Vertebroplasty and Kyphoplasty 01/01/2019
ClinicalPharmacogenetic Testing 11/01/2018
ReimbursementPhysical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction 01/01/2019
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 10/01/2018
AdministrativePractitioner/Provider Administrative Claim Reconsideration and Appeal Process 01/01/2019
AdministrativePrecertification Exemptions for Outpatient Services 01/01/2019
ClinicalPreterm Labor Management 12/01/2018
ClinicalPreventive Care Services 01/01/2019
ReimbursementPreventive Medicine and Screening 07/01/2018
ClinicalPrivate Duty Nursing Services (PDN) 01/01/2019
ReimbursementProcedure and Place of Service 03/01/2019
ReimbursementProlonged Services 03/01/2019
ClinicalProlotherapy for Musculoskeletal Indications 12/01/2018
ClinicalProsthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs 12/01/2018
ClinicalRadiation Therapy Procedures Requiring Precertification for eviCore heathcare Arrangement 03/01/2019
ClinicalRadicava™ (Edaravone) 03/01/2019
ClinicalRadiology Procedures Requiring Precertification for eviCore heathcare Arrangement 01/01/2019
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®) 03/01/2019
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 08/01/2018
ClinicalRituxan® (Rituximab) 03/01/2019
ReimbursementRobotic Assisted Surgery 02/01/2019
ClinicalRoutine Foot Care 01/01/2019
ReimbursementSame Day/Same Service 10/01/2018
ClinicalSandostatin LAR® Depot (Octreotide Acetate) 03/01/2019
ClinicalSensory Integration Therapy and Auditory Integration Training 12/01/2018
ReimbursementServices and Modifiers Not Reimbursable to Healthcare Professionals 01/01/2019
AdministrativeServices Requiring Prior Authorization 03/01/2019
ClinicalShoulder Replacement Surgery (Arthroplasty) 10/01/2018
ClinicalSimponi® Aria (Golimumab) Injection for Intravenous Infusion 03/01/2019
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 01/01/2019
ClinicalSkin and Soft Tissue Substitutes 02/01/2019
ClinicalSodium Hyaluronate 02/01/2019
ClinicalSoliris® (Eculizumab) 03/01/2019
ClinicalSpecialty Medication Administration - Site of Care Review Guidelines 01/01/2019
ReimbursementSpecialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting 10/01/2018
AdministrativeSpeech Therapy and Early Intervention Programs/Birth to Three 10/01/2018
ClinicalSpinraza™ (Nusinersen) 03/01/2019
ReimbursementSplit Surgical Package 07/01/2018
ReimbursementStandby Services 04/01/2018
ClinicalStelara® (Ustekinumab) 03/01/2019
ReimbursementSupply Policy 03/01/2019
ClinicalSurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins 03/01/2019
ClinicalSurgical Treatment for Spine Pain 02/01/2019
ClinicalSynagis® (Palivizumab) 03/01/2019
ReimbursementT Status Codes 01/14/2019
ReimbursementTelehealth and Telemedicine 01/01/2019
ClinicalTemporomandibular Joint Disorders 02/01/2019
ClinicalThermography 12/01/2018
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 03/01/2019
ClinicalTotal Artificial Heart 01/01/2019
ClinicalTotal Knee Replacement Surgery (Arthroplasty) 10/01/2018
ClinicalTranscatheter Heart Valve Procedures 02/01/2019
ClinicalTranscranial Magnetic Stimulation 02/01/2019
ClinicalTranspupillary Thermotherapy 01/01/2019
ClinicalTrogarzo™ (Ibalizumab-Uiyk) 03/01/2019
ClinicalUmbilical Cord Blood Harvesting and Storage for Future Use 01/01/2019
ClinicalUnicondylar Spacer Devices for Treatment of Pain or Disability 01/01/2019
ReimbursementUrgent Care 02/01/2018
ClinicalVaccines 03/01/2019
ClinicalVagus Nerve Stimulation 01/01/2019
ClinicalVirtual Upper Gastrointestinal Endoscopy 12/01/2018
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 03/01/2019
ClinicalWhole Exome and Whole Genome Sequencing 01/01/2019
ReimbursementWrong Surgical or Other Invasive Procedures 03/01/2018
ClinicalXolair® (Omalizumab) 03/01/2019

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