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 01/01/2020
ClinicalAbnormal Uterine Bleeding and Uterine Fibroids 04/01/2020
AdministrativeAbortions (Therapeutic and Elective) 10/01/2019
AdministrativeAccreditation Requirements for Radiology Services 04/01/2019
AdministrativeAcquired Rare Disease Drug Therapy Exception Process 02/01/2020
ClinicalActemra® (Tocilizumab) Injection for Intravenous Infusion 02/01/2020
ReimbursementAcupuncture 11/01/2019
ClinicalAdakveo® (Crizanlizumab-Tmca) 04/01/2020
ReimbursementAdd-On Policy 12/01/2019
ReimbursementAdvanced Practice Health Care Provider 01/01/2020
ReimbursementAfter Hours and Weekend Care 05/01/2019
ClinicalAlpha1-Proteinase Inhibitors 11/01/2019
ReimbursementAmbulance 02/01/2020
AdministrativeAmbulance Services 06/01/2019
ClinicalApheresis 11/01/2019
ClinicalArticular Cartilage Defect Repairs 01/01/2020
AdministrativeAssignment of Benefits & Balance Billing 07/01/2018
ReimbursementAssistant-at-Surgery 01/21/2020
ClinicalAssisted Administration of Clotting Factors, Coagulant Blood Products & Other Hemostatics 01/01/2020
ClinicalAthletic Pubalgia Surgery 06/01/2019
ClinicalAttended Polysomnography for Evaluation of Sleep Disorders 04/01/2020
AdministrativeAutism 01/01/2020
ReimbursementB Bundle Codes 01/01/2020
ClinicalBalloon Sinus Ostial Dilation 01/01/2020
ClinicalBariatric Surgery12/01/2019
AdministrativeBehavioral Health Services 02/01/2020
ClinicalBenlysta® (Belimumab) 02/01/2020
ReimbursementBilateral Procedures 04/01/2020
ClinicalBlepharoplasty, Blepharoptosis and Brow Ptosis Repair 04/01/2020
ClinicalBone or Soft Tissue Healing and Fusion Enhancement Products 01/01/2020
ClinicalBotulinum Toxins A and B 04/01/2020
ClinicalBreast Imaging for Screening and Diagnosing Cancer 11/01/2019
ClinicalBreast Reconstruction Post Mastectomy 02/01/2020
ClinicalBreast Reduction Surgery 02/01/2020
ClinicalBreast Repair/Reconstruction Not Following Mastectomy 11/01/2019
ClinicalBrineura™ (Cerliponase Alfa) 08/01/2019
ClinicalBronchial Thermoplasty 07/01/2019
ClinicalBuprenorphine (Probuphine® & Sublocade™) 10/01/2019
ClinicalCardiac Event Monitoring 04/01/2020
ClinicalCardiology Procedures Requiring Precertification for eviCore healthcare Arrangement 02/01/2020
ClinicalCardiovascular Disease Risk Tests 03/01/2020
ReimbursementCare Plan Oversight 11/01/2019
ClinicalCarrier Testing for Genetic Diseases 07/01/2019
ClinicalChelation Therapy for Non-Overload Conditions 03/01/2019
ClinicalChemosensitivity and Chemoresistance Assays in Cancer 01/01/2020
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 01/01/2020
ClinicalCochlear Implants 04/01/2019
ClinicalCollagen Crosslinks and Biochemical Markers of Bone Turnover 02/01/2019
ClinicalComplement Inhibitors (Soliris® & Ultomiris™) 02/01/2020
ClinicalComputer-Assisted Surgical Navigation for Musculoskeletal Procedures 10/01/2019
ClinicalComputerized Dynamic Posturography 01/01/2020
ReimbursementConsultation Services 10/01/2019
ClinicalContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes 04/01/2020
AdministrativeContraceptives 01/01/2020
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 02/01/2020
ReimbursementCo-Surgeon/Team Surgeon 01/21/2020
AdministrativeCredentialing Guidelines: Participation in the eviCore healthcare Network 02/01/2020
ClinicalCrysvita® (Burosumab-Twza) 01/01/2020
ClinicalCytological Examination of Breast Fluids for Cancer Screening or Diagnosis 04/01/2020
ClinicalDeep Brain and Cortical Stimulation 01/01/2020
ClinicalDenosumab (Prolia® & Xgeva®) 03/01/2020
AdministrativeDental and Oral Surgical Procedures 04/01/2020
AdministrativeDiabetes Supply Coverage 06/01/2019
AdministrativeDialysis Services 03/01/2020
AdministrativeDisclosure Policy 09/01/2018
ClinicalDiscogenic Pain Treatment 10/01/2019
ReimbursementDiscontinued Procedure 08/01/2019
ClinicalDrug Coverage Criteria - New and Therapeutic Equivalent Medications 04/01/2020
ClinicalDrug Coverage Guidelines 04/01/2020
ReimbursementDrug Testing 04/01/2020
AdministrativeDurable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements 01/01/2020
ReimbursementDurable Medical Equipment, Orthotics and Prosthetics 10/01/2019
ClinicalElbow Replacement Surgery (Arthroplasty) 04/01/2020
ClinicalElectric Tumor Treatment Field Therapy 11/01/2019
ClinicalElectrical and Ultrasound Bone Growth Stimulators 04/01/2020
ClinicalElectrical Bioimpedance for Cardiac Output Measurement 09/01/2019
ClinicalElectrical Stimulation and Electromagnetic Therapy for Wounds 03/01/2020
ClinicalElectrical Stimulation for the Treatment of Pain and Muscle Rehabilitation 01/01/2020
ClinicalElectroencephalographic (EEG) Monitoring and Video Recording 04/01/2020
ClinicalEloctate™ (Antihemophilic Factor (Recombinant), FC Fusion Protein) for Connecticut Lines of Business 01/01/2020
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) 02/01/2020
ClinicalEnzyme Replacement Therapy 01/01/2020
ClinicalEpidural Steroid and Facet Injections for Spinal Pain 12/01/2019
ClinicalEpiduroscopy, Epidural Lysis of Adhesions and Discography 01/01/2020
ClinicalErythropoiesis-Stimulating Agents 01/01/2020
ReimbursementEvaluation and Management (E/M) 06/01/2019
ClinicalEvenity™ (Romosozumab-Aqqg) 10/01/2019
ClinicalExondys 51® (Eteplirsen) 04/01/2020
AdministrativeExperimental/Investigational Treatment 02/01/2020
AdministrativeExperimental/Investigational Treatment for NJ Plans 02/01/2020
AdministrativeExtended Benefits for Total Disability & Succeeding Carrier for Inpatient Admissions 12/01/2019
ClinicalExtracorporeal Shock Wave Therapy (ESWT) 06/01/2019
ClinicalFecal Calprotectin Testing 10/01/2019
ClinicalFemoroacetabular Impingement Syndrome Treatment 12/01/2019
ClinicalFetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood 04/01/2020
AdministrativeFiling Deadlines for Claims Submissions 12/01/2019
ClinicalFollicle Stimulating Hormone (FSH) Gonadotropins 01/01/2020
AdministrativeFollow-Up Care Rendered in an Emergency Room Site of Service 02/01/2020
AdministrativeFormula & Specialized Food 03/01/2019
ReimbursementFrom - To Date Policy 01/01/2020
ClinicalFunctional Endoscopic Sinus Surgery (FESS) 11/01/2019
ClinicalGamifant™ (Emapalumab-Lzsg) 10/01/2019
ClinicalGastrointestinal Motility Disorders, Diagnosis and Treatment 04/01/2020
ClinicalGastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea 04/01/2020
ClinicalGender Dysphoria Treatment 01/01/2020
ClinicalGenetic Testing for Cardiac Disease 10/01/2019
ClinicalGenetic Testing for Hereditary Cancer 01/01/2020
ClinicalGenetic Testing for Neuromuscular Disorders 10/01/2019
ClinicalGivlaari™ (Givosiran) 04/01/2020
ClinicalGlaucoma Surgical Treatments 08/01/2019
ReimbursementGlobal Days 01/21/2020
ClinicalGonadotropin Releasing Hormone Analogs 01/01/2020
ClinicalGynecomastia Treatment 04/01/2020
ClinicalHearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable 12/01/2019
ClinicalHigh Frequency Chest Wall Compression Devices 11/01/2019
ClinicalHip Resurfacing and Replacement Surgery (Arthroplasty) 04/01/2020
ClinicalHome Health Care 04/01/2020
ClinicalHome Hemodialysis 04/01/2020
ClinicalHome Traction Therapy 05/01/2019
ClinicalHuman Menopausal Gonadotropins (hMG) 08/01/2019
ClinicalHysterectomy for Benign Conditions 04/01/2020
ClinicalIlaris® (Canakinumab) 10/01/2019
ClinicalIlumya™ (Tildrakizumab-Asmn) 09/01/2019
ClinicalImmune Globulin (IVIG and SCIG) 04/01/2020
ClinicalImmune Globulin - Site of Care 05/01/2019
ClinicalImplantable Beta-Emitting Microspheres for Treatment of Malignant Tumors 04/01/2020
ClinicalImplanted Electrical Stimulator for Spinal Cord 04/01/2020
ReimbursementIncreased Procedural Services 05/01/2019
ClinicalInfertility Diagnosis and Treatment 01/01/2020
ClinicalInfliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) 02/01/2020
ClinicalInhaled Nitric Oxide for Infants 04/01/2020
ClinicalInjectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines 01/01/2020
ReimbursementInjection and Infusion Services 02/01/2020
AdministrativeIn-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy 06/01/2019
ReimbursementIn-Office Laboratory Testing and Procedures List 01/01/2020
AdministrativeInpatient Maternity Stay and Subsequent Home Nursing 12/01/2019
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 10/01/2019
ClinicalIntravenous Iron Replacement Therapy (Feraheme® & Injectafer®) 04/01/2020
ClinicalKnee Replacement Surgery (Arthroplasty), Total and Partial 04/01/2020
ClinicalKrystexxa® (Pegloticase) 01/01/2020
ClinicalLaser Interstitial Thermal Therapy 08/01/2019
ClinicalLemtrada (Alemtuzumab) 06/01/2019
ClinicalLight and Laser Therapy 08/01/2019
ClinicalLithotripsy for Salivary Stones 10/01/2019
ClinicalLower Extremity Vascular Angiography 04/01/2020
ClinicalLuxturna™ (Voretigene Neparvovec-Rzyl) 11/01/2019
ClinicalLyme Disease 11/01/2019
ClinicalMacular Degeneration Treatment Procedures 05/01/2019
ClinicalManipulation Under Anesthesia 02/01/2019
ClinicalManipulative Therapy 12/01/2019
ClinicalMaximum Dosage 11/01/2019
ReimbursementMaximum Frequency Per Day 04/01/2020
AdministrativeMechanical Circulatory Support Device (MCSD) 04/01/2020
ClinicalMechanical Stretching Devices 11/01/2019
AdministrativeMember Administrative Grievance and Appeal (Non UM) Process & Timeframes 12/01/2019
ClinicalMeniscus Implant and Allograft 06/01/2019
ReimbursementMicrosurgery 01/01/2020
ClinicalMifeprex® (Mifepristone) 05/01/2019
ClinicalMinimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) 10/01/2019
ReimbursementModifier Reference 02/01/2020
ReimbursementModifier SU 04/01/2020
ReimbursementMohs Micrographic Surgery 01/01/2020
ClinicalMolecular Oncology Testing for Cancer Diagnosis, Prognosis and Treatment Decisions 04/01/2020
ClinicalMotorized Spinal Traction 05/01/2019
ReimbursementMultiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures 02/01/2020
ReimbursementMultiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging 01/01/2020
ReimbursementMultiple Procedures Payment Reduction (MPPR) for Medical and Surgical Services 01/01/2020
ClinicalNegative Pressure Wound Therapy 02/01/2020
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 12/01/2019
AdministrativeNew York & Connecticut Participating Surgeons Using Non- Participating Providers for Intraoperative Neuro-Monitoring (IONM) 06/01/2018
AdministrativeNewborns 03/01/2020
AdministrativeNon-Participating Provider Consent Form Protocol 03/01/2018
ReimbursementNonphysician Health Care Codes 04/01/2020
ReimbursementNonphysician Health Care Professionals Billing Evaluation and Management Codes 03/01/2020
ReimbursementObservation and Discharge 01/01/2020
ClinicalObservation Care 04/01/2020
ReimbursementObstetrical Policy 06/01/2019
ClinicalObstetrical Ultrasonography 01/01/2020
ClinicalObstructive Sleep Apnea Treatment 04/01/2020
ClinicalOccipital Neuralgia and Headache Treatment 01/01/2020
ClinicalOcrevus™ (Ocrelizumab) 08/01/2019
ClinicalOffice Based Procedures - Site of Service 01/01/2020
ClinicalOff-Label/Unproven Specialty Drug Treatment 07/01/2019
ClinicalOmnibus Codes 01/01/2020
ReimbursementOnce In a Lifetime Procedures 05/01/2019
ReimbursementOne or More Sessions 12/01/2019
ClinicalOnpattro™ (Patisiran) 10/01/2019
ClinicalOrencia® (Abatacept) Injection for Intravenous Infusion 05/01/2019
ClinicalOrthognathic (Jaw) Surgery 04/01/2020
AdministrativeOrthopedic Services 10/01/2019
ClinicalOtoacoustic Emissions Testing 06/01/2019
ClinicalOutpatient Physical & Occupational Therapy for Self-Funded Groups 04/01/2020
ClinicalOutpatient Physical and Occupational Therapy (OptumHealth Care Solutions Arrangement) 04/01/2020
ClinicalOutpatient Surgical Procedures - Site of Service 01/01/2020
ClinicalOxford's Outpatient Imaging Self-Referral 01/01/2020
ClinicalPanniculectomy and Body Contouring Procedures 04/01/2020
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 12/01/2019
ClinicalPercutaneous Vertebroplasty and Kyphoplasty 09/01/2019
ClinicalPharmacogenetic Testing 02/01/2020
ReimbursementPhysical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction 01/01/2020
ClinicalPhysical, Occupational (OptumHealth Care Solutions Arrangement) and Speech Therapy including Cognitive/Neuropsychological Rehabilitation for New Jersey Small Group Members 04/01/2020
ReimbursementPhysician Extenders 12/01/2019
ClinicalPlagiocephaly and Craniosynostosis Treatment 10/01/2019
ClinicalPneumatic Compression Devices 04/01/2020
AdministrativePractitioner/Provider Administrative Claim Reconsideration and Appeal Process 01/01/2019
AdministrativePrecertification Exemptions for Outpatient Services 04/01/2020
ClinicalPreimplantation Genetic Testing 11/01/2019
ClinicalPreventive Care Services 02/01/2020
ReimbursementPreventive Medicine and Screening 06/01/2019
ClinicalPrivate Duty Nursing (PDN) Services 08/01/2019
ReimbursementProcedure and Place of Service 03/01/2020
ReimbursementProlonged Services 04/01/2020
ClinicalProlotherapy and Platelet Rich Plasma Therapies 04/01/2020
ClinicalProsthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs 01/01/2020
ClinicalProvider Administered Drugs – Site of Care 04/01/2020
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 04/01/2020
ClinicalRadiopharmaceuticals and Contrast Media 01/01/2020
ClinicalReblozyl® (Luspatercept-Aamt) 02/01/2020
ReimbursementReduced Services 02/01/2020
AdministrativeReferrals 04/01/2020
ReimbursementReimbursement for Comprehensive and Component CPT Codes 03/01/2020
ReimbursementReplacement Codes 01/01/2020
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 10/01/2019
ClinicalRhinoplasty and Other Nasal Surgeries 04/01/2020
ClinicalRituximab (Rituxan®, Ruxience™ & Truxima®) 04/01/2020
ReimbursementRobotic Assisted Surgery 01/01/2020
ClinicalRoutine Foot Care 10/01/2019
ReimbursementSame Day/Same Service 07/01/2019
ClinicalSandostatin LAR® Depot (Octreotide Acetate) 11/01/2019
ClinicalSensory Integration Therapy and Auditory Integration Training 09/01/2019
ReimbursementServices and Modifiers Not Reimbursable to Healthcare Professionals 01/01/2020
AdministrativeServices Requiring Prior Authorization 04/01/2020
ClinicalShoulder Replacement Surgery (Arthroplasty) 04/01/2020
ClinicalSimponi® Aria (Golimumab) Injection for Intravenous Infusion 05/01/2019
ReimbursementSite of Service Differential 01/01/2020
AdministrativeSkilled Care and Custodial Care Services 08/01/2019
ClinicalSkin and Soft Tissue Substitutes 01/01/2020
ClinicalSodium Hyaluronate 01/01/2020
ReimbursementSpecialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting 04/01/2019
AdministrativeSpeech Therapy and Early Intervention Programs/Birth to Three 01/01/2020
ClinicalSpinraza™ (Nusinersen) 06/01/2019
ReimbursementSplit Surgical Package 12/01/2019
ClinicalSpravato™ (Esketamine) 04/01/2020
ReimbursementStandby Services 12/01/2019
ClinicalStelara® (Ustekinumab) 02/01/2020
ReimbursementSupply Policy 02/01/2020
ClinicalSurgical and Ablative Procedures for Venous Insufficiency and Varicose Veins 03/01/2020
ClinicalSurgical Treatment for Spine Pain 04/01/2020
ClinicalSynagis® (Palivizumab) 08/01/2019
ReimbursementT Status Codes 01/01/2020
ReimbursementTelehealth and Telemedicine 02/01/2020
ClinicalTemporomandibular Joint Disorders 04/01/2020
ClinicalThermography 04/01/2019
ReimbursementTime Span Codes 01/21/2020
AdministrativeTimeframe Standards for Benefit Administrative Initial Decisions 01/01/2020
AdministrativeTimeframe Standards for Utilization Management (UM) Initial Decisions 01/01/2020
ClinicalTotal Artificial Disc Replacement for the Spine 03/01/2020
ClinicalTotal Artificial Heart 09/01/2019
ClinicalTranscatheter Heart Valve Procedures 03/01/2020
ClinicalTranscranial Magnetic Stimulation 04/01/2020
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 12/01/2019
ClinicalVaccines 06/01/2019
ClinicalVagus and External Trigeminal Nerve Stimulation 12/01/2019
ClinicalVertebral Body Tethering for Scoliosis 03/01/2020
ClinicalVirtual Upper Gastrointestinal Endoscopy 09/01/2019
AdministrativeVision Services (Including Refractive Surgery) 09/01/2018
ClinicalVisual Information Processing Evaluation and Orthoptic and Vision Therapy12/01/2019
ClinicalVyondys 53™ (Golodirsen) 04/01/2020
ClinicalWarming Therapy and Ultrasound Therapy for Wounds 10/01/2019
ClinicalWhite Blood Cell Colony Stimulating Factors 04/01/2020
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) 10/01/2019
ClinicalZulresso™ (Brexanolone) 01/01/2020

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