Provider Policies Library | Helpful Resources

Please note that the current policy list is not exhaustive, but rather a collection of policies that providers have expressed an interest in viewing. Amendments, modifications, supplements to these posted policies and/or additional policies may be posted in the near future. If you have any questions regarding these policies, please contact your Provider Relations Representative.

Clinical Policies

Clinical Documents (A-Z)

Clinical Policy: Allogeneic SCT (Adults)

Reference Number: CP.FC.31
PDF Publish Date: 6/1/2023

Clinical Policy: Allogeneic SCT (Pediatric)

Reference Number: CP.FC.32
PDF Publish Date: 1/1/2024

Clinical Policy: Applied Behavior Analysis

Reference Number: CP.FC.BH.301.04
PDF Publish Date: 7/1/2024

Clinical Policy: Autologous SCT (Adults)

Reference Number: CP.FC.30
PDF Publish Date: 3/1/2024

Clinical Policy: Autologous SCT (Pediatric)

Reference Number: CP.FC.33
PDF Publish Date: 3/1/2024

Clinical Policy: Bone-Anchored Hearing Aid

Reference Number: CP.MP.93
PDF Publish Date: 6/1/2024

Clinical Policy: Carpal Tunnel Syndrome Injections

Reference Number: CP.FC.42
PDF Publish Date: 6/1/2024

Clinical Policy: Caudal or Interlaminar ESI

Reference Number: CP.MP.164
PDF Publish Date: 6/1/2024

Clinical Policy: Clinical Policy Committee

Reference Number: CP.CPC.01
PDF Publish Date: 1/1/2024

Clinical Policy: Clinical Policy Web Posting

Reference Number: CP.CPC.02
PDF Publish Date: 8/1/2024

Clinical Policy: Clinical and Preventive Health Guidelines

Reference Number: CP.FC.43
PDF Publish Date: 10/1/2023

Clinical Policy: Clinical Trials

Reference Number: CP.MP.94
PDF Publish Date: 6/1/2024

Clinical Policy: Cochlear Implant Replacements

Reference Number: CP.MP.14
PDF Publish Date: 6/1/2024

Clinical Policy: Cosmetic and Reconstructive Procedures

Reference Number: CP.FC.51
PDF Publish Date: 7/1/2024

Clinical Policy: Denial of Medicaid Non-Covered Benefits

Reference Number: CP.FC.01
PDF Publish Date: 4/1/2024

Clinical Policy: Dental Anesthesia and Facility Services

Reference Number: CP.FC.02
PDF Publish Date: 1/1/2024

Clinical Policy: Diaphragmatic Phrenic Nerve Stimulation

Reference Number: CP.MP.203
PDF Publish Date: 7/1/2024

Clinical Policy: Discography

Reference Number: CP.MP.115
PDF Publish Date: 5/1/2024

Clinical Policy: Donor Lymphocyte Infusion

Reference Number: CP.MP.101
PDF Publish Date: 4/1/2024

Clinical Policy: Donor Lymphocyte Infusion (Medicare)

Reference Number: MC.CP.MP.101
PDF Publish Date: 2/1/2024

Clinical Policy: Durable Medical Equipment (DME), Orthotics & Prosthetics

Reference Number: CP.FC.06
PDF Publish Date: 7/1/2024

Clinical Policy: Electric Tumor Treating Fields (Optune)

Reference Number: CP.MP.145
PDF Publish Date: 11/1/2023

Clinical Policy: Experimental Technologies

Reference Number: CP.MP.36
PDF Publish Date: 4/1/2024

Clinical Policy: Facet Joint Interventions

Reference Number: CP.FC.18
PDF Publish Date: 12/1/2023

Clinical Policy: Facility-Based Sleep Studies for Obstructive Sleep Apnea

Reference Number: MC.CP.MP.248
PDF Publish Date: 1/1/2024

Clinical Policy: Fecal Incontinence Treatments

Reference Number: CP.MP.137
PDF Publish Date: 6/1/2024

Clinical Policy: Fertility Preservation

Reference Number: CP.FC.15
PDF Publish Date: 12/1/2023

Clinical Policy: Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Reference Number: CP.MP.129
PDF Publish Date: 6/1/2024

Clinical Policy: Gastric Electrical Stimulation

Reference Number: CP.MP.40
PDF Publish Date: 3/1/2023

Clinical Policy: Genetic Testing

Reference Number: CP.FC.49
PDF Publish Date: 4/1/2024

Clinical Policy: Heart-Lung Transplant

Reference Number: CP.MP.132
PDF Publish Date: 3/1/2023

Clinical Policy: Home Births

Reference Number: CP.FC.21
PDF Publish Date: 2/1/2024

Clinical Policy: Home Health Criteria for Prenatal and Postpartum Nursing Visits & Home Health Aide Services

Reference Number: CP.FC.04
PDF Publish Date: 8/1/2024

Clinical Policy: Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

Reference Number: CP.MP.180
PDF Publish Date: 8/1/2024

Clinical Policy: Implantable Wireless PAP Monitoring

Reference Number: CP.MP.160
PDF Publish Date: 4/1/2024

Clinical Policy: Implantable Wireless PAP Monitoring (Medicare)

Reference Number: MC.CP.MP.160
PDF Publish Date: 2/1/2024

Clinical Policy: Injections for Morton’s Neuroma

Reference Number: CP.FC.26
PDF Publish Date: 12/1/2023

Clinical Policy: Intradiscal Steroid Injections for Pain Management

Reference Number: CP.MP.167
PDF Publish Date: 8/1/2023

Clinical Policy: Intestinal and Multivisceral Transplant

Reference Number: CP.MP.58
PDF Publish Date: 5/1/2024

Clinical Policy: Keratoplasty

Reference Number: CP.VP.36
PDF Publish Date: 11/1/2023

Clinical Policy: Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy

Reference Number: CP.MP.250
PDF Publish Date: 7/1/2024

Clinical Policy: Laser Therapy for Skin Conditions

Reference Number: CP.MP.123
PDF Publish Date: 3/1/2024

Clinical Policy: Liposuction for Lipedema

Reference Number: CP.MP.244
PDF Publish Date: 5/1/2024

Clinical Policy: Lung Transplantation

Reference Number: CP.MP.57
PDF Publish Date: 4/1/2024

Clinical Policy: Lung Transplantation (Medicare)

Reference Number: MC.CP.MP.57
PDF Publish Date: 2/1/2024

Clinical Policy: Lysis of Epidural Lesions

Reference Number: CP.MP.116
PDF Publish Date: 5/1/2024

Clinical Policy: Mechanical Stretching Devices

Reference Number: CP.MP.144
PDF Publish Date: 12/1/2023

Clinical Policy: Medical Necessity Criteria

Reference Number: CP.FC.05
PDF Publish Date: 7/1/2024

Clinical Policy: Multiple Sleep Latency Testing

Reference Number: CP.MP.24
PDF Publish Date: 5/1/2024

Clinical Policy: Nasal Valve Repair Investigational Procedures

Reference Number: CP.FC.50
PDF Publish Date: 9/1/2024

Clinical Policy: Nerve Blocks for Pain Management

Reference Number: CP.MP.170
PDF Publish Date: 6/18/2024

Clinical Policy: Neuropsychological, Psychological, and Developmental Testing

Reference Number: CP.FC.BH.301.04
PDF Publish Date: 4/1/2024

Clinical Policy: Nonmyeloablative Allogeneic SCT

Reference Number: CP.MP.141
PDF Publish Date: 3/30/2024

Clinical Policy: Omisirge (omidubicel): Nicotinamide-modified Allogeneic Hematopoietic Progenitor Cell Therapy

Reference Number: CP.MP.249
PDF Publish Date: 6/1/2024

Clinical Policy: Orthognathic Surgery

Reference Number: CP.MP.202
PDF Publish Date: 8/1/2024

Clinical Policy: Out-of-Network

Reference Number: CP.FC.20
PDF Publish Date: 8/1/2024

Clinical Policy: Ovulation Induction and Infertility

Reference Number: CP.FC.14
PDF Publish Date: 12/1/2023

Clinical Policy: Pancreas Transplantation

Reference Number: CP.MP.102
PDF Publish Date: 3/30/2024

Clinical Policy: Panniculectomy

Reference Number: CP.MP.109
PDF Publish Date: 8/1/2024

Clinical Policy: Pasteurized Donor Human Milk

Reference Number: CP.FC.36
PDF Publish Date: 4/1/2024

Clinical Policy: Pediatric Heart Transplant

Reference Number: CP.MP.138
PDF Publish Date: 8/1/2024

Clinical Policy: Pediatric Kidney Transplant

Reference Number: CP.MP.246
PDF Publish Date: 4/1/2024

Clinical Policy: Pediatric Kidney Transplant (Medicare)

Reference Number: MC.CP.MP.246
PDF Publish Date: 2/1/2024

Clinical Policy: Pediatric Liver Transplant

Reference Number: CP.MP.120
PDF Publish Date: 5/1/2024

Clinical Policy: Pediatric Oral Function Therapy

Reference Number: CP.MP.188
PDF Publish Date: 5/1/2024

Clinical Policy: Penile Prosthesis Implantation

Reference Number: CP.FC.44
PDF Publish Date: 6/1/2024

Clinical Policy: PFO Closure Devices

Reference Number: CP.MP.151
PDF Publish Date: 11/1/2023

Clinical Policy: Polysomnography (PSG)

Reference Number: CP.FC.22
PDF Publish Date: 9/1/2024

Clinical Policy: Posterior Tibial Nerve Stimulation for-Voiding Dysfunction

Reference Number: CP.MP.133
PDF Publish Date: 7/1/2024

Clinical Policy: Reduction Mammoplasty and Gynecomastia Surgery

Reference Number: CP.MP.51
PDF Publish Date: 6/1/2024

Clinical Policy: Repeat Bariatric Surgery

Reference Number: CP.FC.24
PDF Publish Date: 7/1/2024

Clinical Policy: Sacroiliac Joint Interventions

Reference Number: CP.MP.166
PDF Publish Date: 7/1/2024

Clinical Policy: Sclerotherapy for Varicose Veins

Reference Number: CP.MP.146
PDF Publish Date: 4/1/2024

Clinical Policy: Selective Dorsal Rhizotomy for Spasticity

Reference Number: CP.MP.174
PDF Publish Date: 11/1/2023

Clinical Policy: Services not on Fee Schedule

Reference Number: CP.FC.41
PDF Publish Date: 6/18/2024

Clinical Policy: Short Inpatient Hospital Stay (HBX)

Reference Number: CP.FC.28
PDF Publish Date: 2/1/2024

Clinical Policy: Short Inpatient Hospital Stay (Medicare)

Reference Number: MC.CP.FC.182
PDF Publish Date: 12/1/2023

Clinical Policy: Sickle Cell Anemia and β-Thalassemia Cell Transplant

Reference Number: CP.MP.108
PDF Publish Date: 8/1/2024

Clinical Policy: Sickle Cell Anemia and β-Thalassemia Cell Transplant (Medicare)

Reference Number: MC.CP.MP.108
PDF Publish Date: 2/1/2024

Clinical Policy: Skin Substitutes Policy

Reference Number: CP.FC.34
PDF Publish Date: 8/1/2024

Clinical Policy: State CP Process

Reference Number: CP.FC.40
PDF Publish Date: 12/1/2023

Clinical Policy: Tandem Transplant

Reference Number: CP.MP.162
PDF Publish Date: 3/30/2024

Clinical Policy: Tendon Injection

Reference Number: CP.FC.27
PDF Publish Date: 1/1/2024

Clinical Policy: Therapeutic Utilization of Inhaled Nitric Oxide

Reference Number: CP.MP.87
PDF Publish Date: 7/1/2024

Clinical Policy: Thyroid Nodule Genetic Testing

Reference Number: CP.FC.35
PDF Publish Date: 9/1/2024

Clinical Policy: Total Artificial Heart

Reference Number: CP.MP.127
PDF Publish Date: 6/1/2024

Clinical Policy: Transfer Policy

Reference Number: CP.FC.03
PDF Publish Date: 8/1/2023

Clinical Policy: Transforaminal Epidural Injections

Reference Number: CP.MP.165
PDF Publish Date: 7/1/2024

Clinical Policy: Transplant Service Documentation Requirements

Reference Number: CP.MP.247
PDF Publish Date: 11/1/2023

Clinical Policy: Trigger Point Injections

Reference Number: CP.MP.169
PDF Publish Date: 7/1/2024

Clinical Policy: Urinary Incontinence Devices and Treatments

Reference Number: CP.MP.142
PDF Publish Date: 11/1/2023

Clinical Policy: Vagus Nerve Stimulation

Reference Number: CP.MP.12
PDF Publish Date: 7/1/2024

Clinical Policy: Ventricular Assist Devices

Reference Number: CP.MP.46
PDF Publish Date: 3/1/2024

Clinical Policy: Wireless Motility Capsule

Reference Number: CP.MP.143
PDF Publish Date: 10/1/2023

Payment Policies

Payment Documents (A-Z)

Payment Policy: 14 Day Readmission (Medicaid)

Reference Number: FC.PP.003
PDF Publish Date: 11/1/2022

Payment Policy: 25-hydroxyvitamin D Testing in Children and Adolescents

Reference Number: FC.PP.027
PDF Publish Date: 10/1/2023

Payment Policy: 30 Day Readmission (Medicare)

Reference Number: FC.PP.004
PDF Publish Date: 2/1/2023

Payment Policy: Allergy Testing and Therapy

Reference Number: FC.PP.026
PDF Publish Date: 10/1/2023

Payment Policy: Bronchial Thermoplasty

Reference Number: FC.PP.017
PDF Publish Date: 4/1/2023

Payment Policy: Claim Validation of Modifier 25

Reference Number: FC.PP.001
PDF Publish Date: 11/1/2022

Payment Policy: Claim Validation of Modifier 59

Reference Number: FC.PP.002
PDF Publish Date: 11/1/2022

Payment Policy: Clean Claim Reviews

Reference Number: FC.PP.036
PDF Publish Date: 6/1/2024

Payment Policy: CMS Correct Coding Initiative

Reference Number: FC.PP.020
PDF Publish Date: 11/15/2022

Payment Policy: Cost to Charge Adjustments on Clean Claim Reviews

Reference Number: FC.PP.037
PDF Publish Date: 6/1/2024

Payment Policy: Digital EEG Spike Analysis

Reference Number: FC.PP.011
PDF Publish Date: 3/1/2024

Payment Policy: EEG in the Evaluation of Headache

Reference Number: FC.PP.014
PDF Publish Date: 10/1/2023

Payment Policy: Emergency Department Evaluation and Management Claim Adjustment

Reference Number: FC.PP.005
PDF Publish Date: 5/1/2024

Payment Policy: Endometrial Ablation

Reference Number: FC.PP.010
PDF Publish Date: 4/1/2023

Payment Policy: Evaluation and Management Claim Adjustment

Reference Number: FC.PP.006
PDF Publish Date: 6/1/2023

Payment Policy: Evoked Potential Testing

Reference Number: FC.PP.019
PDF Publish Date: 12/1/2023

Payment Policy: Gastrointestinal Pathogen Nucleic Acid Detection Panel

Reference Number: FC.PP.034
PDF Publish Date: 11/1/2022

Payment Policy: Helicobacter Pylori Serology Testing

Reference Number: FC.PP.018
PDF Publish Date: 10/1/2023

Payment Policy: Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy

Reference Number: FC.PP.028
PDF Publish Date: 4/1/2023

Payment Policy: Maximum Units of Service

Reference Number: CC.PP.007
PDF Publish Date: 1/1/2023

Payment Policy: Measure of Serum 1.25 (Vitamin D)

Reference Number: FC.PP.012
PDF Publish Date: 12/1/2023

Payment Policy: National Diabetes Prevention Program (NDPP)

Reference Number: FC.PP.021
PDF Publish Date: 6/1/2023

Payment Policy: Non-obstetrical and Obstetrical Transabdominal & Transvaginal Ultrasounds

Reference Number: FC.PP.009
PDF Publish Date: 3/1/2023

Payment Policy: Pre-Payment and Post-Payment Review (Non-Medicare)

Reference Number: FC.PP.007
PDF Publish Date: 11/1/2021

Payment Policy: Pre-Payment and Post-Payment Review (Medicare)

Reference Number: FC.PP.008
PDF Publish Date: 1/1/2022

Payment Policy: Pulmonary Function Testing

Reference Number: FC.PP.035
PDF Publish Date: 11/1/2022

Payment Policy: Renal Hemodialysis

Reference Number: CC.PP.067
PDF Publish Date: 9/1/2022

Payment Policy: Robotic Surgery

Reference Number: CC.PP.050
PDF Publish Date: 3/1/2023

Payment Policy: Sepsis Diagnosis

Reference Number: CC.PP.073
PDF Publish Date: 3/1/2023

Payment Policy: Skilled Nursing Facility Leveling

Reference Number: CC.PP.206
PDF Publish Date: 8/1/2024

Payment Policy: Spinal Muscular Atrophy (SMA) Carrier Screening in Pregnancy

Reference Number: FC.PP.033
PDF Publish Date: 6/1/2022

Payment Policy: Status "B" Bundled Services

Reference Number: CC.PP.046
PDF Publish Date: 1/1/2023

Payment Policy: Status "P" Bundled Services

Reference Number: CC.PP.049
PDF Publish Date: 1/1/2023

Payment Policy: Testing for Select Genitourinary Conditions

Reference Number: FC.PP.022
PDF Publish Date: 12/1/2023

Payment Policy: Thyroid Insulin Tests in Pediatrics

Reference Number: FC.PP.013
PDF Publish Date: 10/1/2023

Payment Policy: Transgender Services Billing Requirements

Reference Number: CC.PP.047
PDF Publish Date: 4/1/2023

Payment Policy: Ultrasound in Pregnancy

Reference Number: FC.PP.029
PDF Publish Date: 12/1/2023

Payment Policy: Unbundling Adjustments on Clean Claim Reviews

Reference Number: FC.PP.038
PDF Publish Date: 6/1/2024

Payment Policy: Urodynamic Testing

Reference Number: FC.PP.023
PDF Publish Date: 1/1/2024

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